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<p>Begin Reading</p><p>Table of Contents</p><p>About the Author</p><p>Copyright Page</p><p>Thank you for buying this</p><p>Flatiron Books ebook.</p><p>To receive special offers, bonus content,</p><p>and info on new releases and other great reads,</p><p>sign up for our newsletters.</p><p>Or visit us online at</p><p>us.macmillan.com/newslettersignup</p><p>For email updates on the author, click here.</p><p>http://us.macmillan.com/newslettersignup?utm_source=ebook&utm_medium=adcard&utm_term=ebookreaders&utm_content=michaelgreger_newslettersignup_macdotcom&utm_campaign=9781250199249</p><p>http://us.macmillan.com/newslettersignup?utm_source=ebook&utm_medium=adcard&utm_term=ebookreaders&utm_content=michaelgreger_newslettersignup_macdotcom&utm_campaign=9781250199249</p><p>https://us.macmillan.com/authoralerts?authorName=michaelgreger&authorRefId=109690374&utm_source=ebook&utm_medium=adcard&utm_term=ebookreaders&utm_content=michaelgreger_authoralertsignup_macdotcom&utm_campaign=9781250199249</p><p>The author and publisher have provided this e-book to you for your</p><p>personal use only. You may not make this e-book publicly available in any</p><p>way. Copyright infringement is against the law. If you believe the copy</p><p>of this e-book you are reading infringes on the author’s copyright,</p><p>please notify the publisher at: us.macmillanusa.com/piracy.</p><p>http://us.macmillanusa.com/piracy</p><p>To my mom,</p><p>the source of everything good in my life</p><p>Preface</p><p>DOWN THE RABBIT HOLE</p><p>Surely, if there were a safe, simple, side effect–free solution to obesity, we</p><p>would know about it by now, right?</p><p>I’m not so sure.</p><p>It takes an estimated average of seventeen years before evidence from</p><p>scientific research is incorporated into day-to-day clinical practice.1 One</p><p>example that was particularly poignant for my family: heart disease.</p><p>Decades ago, Dr. Dean Ornish and colleagues published evidence in one of</p><p>the most prestigious medical journals in the world that our leading cause of</p><p>death could be reversed with diet and lifestyle changes alone2—yet this</p><p>monumental discovery was effectively ignored at the time.3 Even now,</p><p>hundreds of thousands of Americans continue to perish every year from</p><p>what we learned nearly thirty years ago is an arrestable, reversible</p><p>condition. In fact, I had seen such a reversal with my own eyes.</p><p>My dear grandmother was cured of her end-stage heart disease by one of</p><p>Ornish’s contemporaries, Nathan Pritikin, using similar methods. She was</p><p>sixty-five when she was given her medical death sentence, but—thanks to a</p><p>healthy diet—was able to live another thirty-one years to age ninety-six, to</p><p>continue enjoying her six grandkids, including me.</p><p>If effectively the cure to the number-one killer of men and women could</p><p>be ignored and get lost down some rabbit hole, what else might be buried in</p><p>the medical literature? I’ve made it my life’s mission to find out. That’s</p><p>why I went to medical school in the first place and why I started</p><p>NutritionFacts.org.</p><p>So, like heart disease, might there already be a cure for obesity? That’s</p><p>what I intended to uncover.</p><p>Here’s the problem: I hate diet books. Furthermore, I hate diet books that</p><p>purport to hate diet books yet relish in all the same absurdities. This book is</p><p>for those who want facts, not filler, fantasy, or fluff. If you want</p><p>testimonials and before-and-after pictures, you’ve come to the wrong place.</p><p>You don’t need anecdotes when you have evidence. A Harvard sociologist</p><p>of science calls those arguments by anecdotes in diet books “a deliberate</p><p>attempt at credibility engineering.”4 When you don’t have the science to</p><p>back you up, all you have are “success” stories.</p><p>I’m not interested in offering dueling anecdotes, nor am I interested in</p><p>dietary dogma, beliefs, or opinions. What I am interested in is the science.</p><p>When it comes to making life-and-death decisions that concern something</p><p>as important as your own health and that of your family, as far as I’m</p><p>concerned, there’s only one question: What does the best available balance</p><p>of evidence say right now? That’s what I’ve tried to encapsulate in this</p><p>book.</p><p>Often, diet books deal in pseudoscientific twaddle swaddled in the</p><p>trappings of science. But how is the untrained reader supposed to know the</p><p>difference between the two and decide among the competing claims? It’s no</p><p>wonder people tend to flock to their respective gurus to have their minds</p><p>made up for them. However, no one is born with this knowledge—and you</p><p>have a right to demand to know where diet book authors got the information</p><p>they’re trying to sell you so you can check the credibility of the source and</p><p>confirm its veracity. That’s why I prefer presenting the science in video</p><p>format on my website, where I can show the original data and link to</p><p>downloads of all the primary sources. And here in this book, I’ve tried to</p><p>cite each substantive statement of fact.</p><p>My goal was to create the oxymoron: an evidence-based diet book.</p><p>CAVEAT EATER</p><p>No other area of the national health probably is as abused by</p><p>deception and misinformation as nutrition. Many travesties cheat</p><p>the public of enormous sums of money, and of good health as well.</p><p>—WHITE HOUSE CONFERENCE ON FOOD, NUTRITION, AND HEALTH5</p><p>Frustrated by the current political climate of alternative facts and echo</p><p>chambers? Welcome to my world. The entire diet industry is built upon a</p><p>foundation of fake news. The nutrition field has been dealing with bald-</p><p>faced lies since back in the pre-post-truth era, and diet books can be the</p><p>worst offenders. “Often the loudest, most extreme voices drown out the</p><p>well informed,” wrote two noted nutrition professors on the subject of diet</p><p>books. “There is also money to be made.”6</p><p>Lots of money. Every month seems to bring us a trendy new diet or</p><p>weight-loss fad, and they always sell because they always fail. The diet</p><p>industry may rake in up to $50 billion a year, and the business model is</p><p>based on repeat customers.7 Racked with the guilt and self-hatred of failure,</p><p>people often line right back up to be fooled again. I hope this book can help</p><p>break that cycle by cutting through the BS.</p><p>Beyond the corrupting influence of commercial interests are the</p><p>ideological biases. Too often in diet books, the rule is to obfuscate rather</p><p>than illuminate, cherry-pick facts to push some pet theory, and ignore the</p><p>rest to promote your own agenda. It’s the opposite of science. In true</p><p>scholarship, your conclusions follow from the evidence, not the other way</p><p>around.</p><p>Unfortunately, even just sticking to the peer-reviewed scientific literature</p><p>is not enough. An article in The New England Journal of Medicine on</p><p>obesity myths concluded that “false and scientifically unsupported beliefs</p><p>about obesity are pervasive” in medical journals as well.8 In that case, the</p><p>only way to get at the truth is to dive deep into the primary literature and</p><p>read all the original studies yourself rather than taking some contemporary</p><p>reviewer’s word for it. But who’s got time for that? There are more than</p><p>half a million scientific papers on the subject of obesity, with a hundred</p><p>new ones published every day. Even researchers in the field might only be</p><p>able to keep track of what’s going on in their narrow, subspecialized</p><p>domains. But that’s precisely what we do at NutritionFacts.org. We comb</p><p>through tens of thousands of studies a year so you don’t have to.</p><p>This is the kind of book I was made for. My research team and I were</p><p>allowed to really flex our muscles, and the sorer those muscles got, the</p><p>further we stretched ourselves, the more valuable we realized this</p><p>contribution would be. Even “simple” questions on weight loss, like</p><p>whether you should eat breakfast or skip it, or whether it’s better to exercise</p><p>before or after meals, turned into major, thousand-article research projects.</p><p>If our nose-to-the-grindstone research team had trouble sifting through the</p><p>stacks, a practicing physician would have no chance and the public would</p><p>be totally lost.</p><p>Whether you’re morbidly obese, just overweight like the average</p><p>American, or at your ideal weight and wanting to keep it that way, our goal</p><p>was to give you every</p><p>of junk food?”221 Pediatricians are now encouraged to have</p><p>the “French Fry Discussion” with parents at the twelve-month “well-child</p><p>visit” and no longer wait until kids are two years old.222 And even that may</p><p>be too late. Two-thirds of infants are fed junk food before their first</p><p>birthday.223</p><p>Dr. David L. Katz may have said it best in Harvard Health Policy</p><p>Review:</p><p>Those who contend that parental or personal responsibility should</p><p>carry the day despite these environmental temptations might consider</p><p>the implications of generalizing the principle. Perhaps children</p><p>should be encouraged, but not required, to attend school and tempted</p><p>each morning by alternatives, such as buses to the circus, zoo, or</p><p>beach.224</p><p>Is Big Food Making Us Big Too?</p><p>The plague of tobacco-related deaths wasn’t just due to the mass</p><p>manufacture and marketing of cheap cigarettes. Tobacco companies</p><p>actively sought to make their products even more craveable by spraying the</p><p>sheets of tobacco with nicotine and additives like ammonia to provide a</p><p>bigger nicotine kick.225 The food industry employs taste engineers to</p><p>accomplish a similar goal: maximize the irresistibility of their products.</p><p>Taste is the leading factor in food choice.226 Salt, sugar, and fat are used</p><p>as the three points of the compass to create “superstimulating”</p><p>“hyperpalatability” to tempt people into impulsive buys and compulsive</p><p>consumption.227 Foods are designed intentionally to hook into our</p><p>evolutionary triggers and breach whatever biological barriers help keep</p><p>consumption within reasonable limits.228</p><p>Big Food is big business. The processed food industry alone brings in</p><p>more than $2 trillion a year.229 That affords it the economic might to</p><p>manipulate more than just taste profiles; it influences public policy and</p><p>scientific inquiry as well. The food, alcohol, and tobacco industries have all</p><p>used similar unsavory tactics: blocking health regulations, co-opting</p><p>professional organizations, creating front groups, and distorting the</p><p>science.230 The common playbook shouldn’t be surprising given the many</p><p>common corporate threads—at one time, for example, cigarette giant Philip</p><p>Morris owned both Kraft and Miller Brewing.231</p><p>In 2009, the food industry spent more than $50 million to hire 350</p><p>lobbyists to influence legislation, most of whom were “revolvers,” former</p><p>federal employees in the revolving door between industry and its regulators.</p><p>They could push corporate interests from the inside and then turn around</p><p>and be rewarded with cushy lobbying jobs after their “public service.”232</p><p>In the following year, the food industry acquired a new weapon, a stick</p><p>to go along with all those carrots. On January 21, 2010, the Supreme</p><p>Court’s 5–4 Citizens United ruling permitted corporations to spend</p><p>unlimited amounts of money on campaign ads to trash anyone who dared</p><p>stand against them.233 No wonder our elected officials have so thoroughly</p><p>shrunk from the fight,234 leaving us largely with a government of Big Food,</p><p>by Big Food, and for Big Food.235</p><p>Globally, a similar dynamic exists. Weak tea calls from the public health</p><p>community for voluntary standards are met not only with vicious fights</p><p>against meaningful change236 but also massive transnational trade and</p><p>foreign investment deals that cement protection of food industry profits into</p><p>the laws of the lands.237</p><p>The corrupting commercial influence even extends to medical</p><p>associations. Reminiscent of the “Just what the doctor ordered” cigarette</p><p>ads of yesteryear,238 the American Academy of Family Physicians has</p><p>accepted millions from the Coca-Cola Company, in part to explicitly</p><p>“develop consumer education content on beverages and sweeteners.”239</p><p>When the American Academy of Pediatrics was called out for its proud new</p><p>corporate relationship with Coke and the company’s “invaluable</p><p>commitment to children’s health,”240 an executive vice president of the</p><p>academy tried to quell protest by explaining that this alliance was not</p><p>without precedent: The American Academy of Pediatrics had had</p><p>relationships with Pepsi and McDonald’s for some time.241</p><p>On the front line, fake grassroots “AstroTurf” groups are used to mask</p><p>the corporate message. In the footsteps of Get Government Off Our Back,</p><p>memorably acronymed GGOOB and created by R. J. Reynolds to fight</p><p>tobacco regulation, the front group Americans Against Food Taxes may just</p><p>as well be called Food Industry Against Food Taxes.242 The power of front-</p><p>group formation was enough to bind two bitter corporate rivals, the Sugar</p><p>Association and the Corn Refiners Association, and have them link arms</p><p>with the American Beverage Association and the National Confectioners</p><p>Association to partner together as Americans for Food and Beverage</p><p>Choice.243</p><p>Another tried-and-true tobacco industry tactic:244 Research front groups</p><p>like Coca-Cola’s Global Energy Balance Network can be used to subvert</p><p>the scientific process by shaping245 or suppressing246 science that deviates</p><p>from the corporate agenda. The trans fat story is one of many examples.</p><p>Food manufacturers have not only long denied that trans fat was associated</p><p>with disease,247 they actively worked to limit inquiry248 and discredit</p><p>research findings.249</p><p>One estimate places the global death toll from foods high in trans fat,</p><p>saturated fat, salt, and sugar at fourteen million lost lives. Every year.250 The</p><p>inability of countries around the world to turn the tide on obesity “is not a</p><p>failure of individual will-power,” said the director-general of the World</p><p>Health Organization.251 “It is a failure of political will to take on the</p><p>powerful food and soda industries.”252 She ended her keynote address</p><p>entitled “Obesity and Diabetes: The Slow-Motion Disaster” before the</p><p>National Academy of Medicine with these words: “The interests of the</p><p>public must be prioritized over those of corporations.”253</p><p>We Have to Stop Eating Like This</p><p>When it comes to uncovering the root causes of the obesity epidemic, there</p><p>appears to be a sort of manufactured confusion. Major studies assert the</p><p>causes are “extremely complex” and “fiendishly hard to untangle.”254</p><p>Having just reviewed the literature, it doesn’t seem like much of a mystery</p><p>to me.</p><p>It’s the food.</p><p>Attempts at obfuscation—rolling out hosts of implausible explanations</p><p>like sedentary lifestyles or lack of self-discipline—serve the needs of the</p><p>manufacturers and marketers more than the public’s health and the interest</p><p>of truth.255 When asked about the role of restaurants in the obesity epidemic,</p><p>the president of the National Restaurant Association replied, “Just because</p><p>we have electricity doesn’t mean you have to electrocute yourself.”256 Yes,</p><p>but much of the food industry is effectively attaching electrodes to shock</p><p>and awe the reward centers in our brains to undermine our self-control.</p><p>Advances in processing and packaging, combined with government</p><p>policies and handouts that fostered cheap commodities for the “food</p><p>industrial complex,”257 led to a glut of ready-to-eat, ready-to-heat, or ready-</p><p>to-drink products. To help assuage impatient investors, marketing became</p><p>ever-more pervasive and persuasive. All these factors conspired to create</p><p>unfettered access to copious, convenient, low-cost, high-calorie foods often</p><p>willfully engineered with chemical additives to be hyperstimulatingly sweet</p><p>or savory, yet only weakly satiating.</p><p>As we each sink deeper into a quicksand of calories, more and more</p><p>mental energy is required to swim upstream against the constant</p><p>bombardment of advertising and 24–7 panopticon of arm’s-length tempting</p><p>treats.258 There’s so much food flooding the market now that much of it ends</p><p>up in the trash. Food waste has progressively increased by about 50 percent</p><p>since the 1970s.259 Perhaps better in the landfill, though, than filling up our</p><p>stomachs. And too many of these cheap, fattening foods prioritize shelf life</p><p>over human life.</p><p>But dead people don’t eat. Don’t food companies have a vested interest</p><p>in keeping their consumers healthy? A question such as this reveals a</p><p>fundamental misunderstanding</p><p>of the system. A public company’s primary</p><p>responsibility is to reap returns for investors. Consider the fact that the</p><p>tobacco industry produces products that kill one in two of its most loyal</p><p>customers.260 It’s not about customer satisfaction but shareholder</p><p>satisfaction. The customer always comes second.</p><p>Just as weight gain may be a perfectly natural reaction to a fattening</p><p>food environment, governments and businesses are just responding</p><p>normally to the political and economic realities of our system.261 Can you</p><p>think of a single major industry that would benefit from people eating less</p><p>junk? “Certainly not the agriculture, food product, grocery, restaurant, diet,</p><p>or drug industries,” emeritus professor Marion Nestle wrote in a Science</p><p>editorial when she was chair of nutrition at New York University. “All</p><p>flourish when people eat more, and all employ armies of lobbyists to</p><p>discourage governments from doing anything” about it.262</p><p>If part of the problem is cheap, tasty convenience, is the solution hard-to-</p><p>find food that’s unappealing and expensive? Or might there be a way to get</p><p>the best of all worlds—easy, healthy, delicious, satisfying meals that help</p><p>you lose weight?</p><p>I wrote this book to find out.</p><p>THE CONSEQUENCES</p><p>As Queasy as ABC</p><p>The largest study in history on the health effects of being overweight</p><p>analyzed data from more than fifty million people in nearly two hundred</p><p>countries and found that too much excess body weight accounts for the</p><p>premature deaths of about four million people every year. Most of these</p><p>deaths are from heart disease, but the researchers found “convincing” or</p><p>“probable” evidence linking obesity to twenty different disorders263—a</p><p>veritable alphabet soup of potential health concerns.</p><p>A Is for Arthritis</p><p>In the ABCs of health consequences, A is for arthritis. Obesity can worsen</p><p>rheumatoid arthritis264 and increase the risk of another inflammatory joint</p><p>disease,265 gout, known as the disease of kings thanks to their overly rich</p><p>diets. The most common joint disease in the world, though, is</p><p>osteoarthritis,266 and obesity may be its main modifiable risk factor.267</p><p>Osteoarthritis develops when the cushioning cartilage lining of joints breaks</p><p>down faster than the body can build it back up.268 The knees are the most</p><p>commonly affected, leading to the assumption that the disease’s relationship</p><p>to obesity was simply the excess wear and tear from added load on the</p><p>joints. Non-weight-bearing joints, like the hands and wrists, can also be</p><p>affected, however, which suggests the link isn’t purely mechanical. Obesity-</p><p>related dyslipidemia may be playing a role,269 with elevations in the amount</p><p>of fat, cholesterol, and triglycerides in the blood aggravating inflammation</p><p>in the joints.270</p><p>Losing just around a pound a year over a span of a decade may decrease</p><p>the odds of developing osteoarthritis by more than 50 percent.271 Weight</p><p>reduction may even obviate the need for knee replacement surgery. Within</p><p>just eight weeks, obese osteoarthritis sufferers who had been randomized to</p><p>lose weight improved their knee function as much as those going through</p><p>surgery. Researchers concluded that losing around twenty pounds of fat</p><p>“might be regarded as an alternative to knee replacement.”272</p><p>But isn’t it easier to just get your knee replaced than lose twenty pounds?</p><p>Rarely discussed is the fact that nearly one in two hundred knee</p><p>replacement patients dies within ninety days of surgery. Given the extreme</p><p>popularity of the operation—about seven hundred thousand are performed</p><p>each year in the United States—an orthopedics journal editor suggested that</p><p>“people considering this operation are inadequately attuned to the</p><p>possibility that it may kill them.”273 A surgeon responded by questioning</p><p>whether patients should be told about what is arguably the “single most-</p><p>salient fact”:274</p><p>To me, the real question is whether this knowledge will help the</p><p>patient. Will it add to the anxiety of the already-anxious patient,</p><p>perhaps to the point of denying that patient a helpful operation? Or</p><p>will this knowledge motivate a less-handicapped patient to stick to a</p><p>diet and physical activity regime? Ultimately, then, the question boils</p><p>down to the surgeon’s judgment.275</p><p>Even among the vast majority who survive the surgery, approximately</p><p>one in five knee replacement patients describes being unsatisfied with the</p><p>outcome.276 Weight loss, on the other hand, may offer a nonsurgical</p><p>alternative that instead treats the cause and offers only beneficial side</p><p>effects.</p><p>B Is for Back Pain and Blood Pressure</p><p>Being overweight is also a risk factor for low back pain,277 sciatica,278</p><p>lumbar disc degeneration,279 and herniation.280 As with arthritis, this may be</p><p>due to the combination of the hefty joint load plus the inflammation and</p><p>cholesterol associated with being heavier.281 Autopsy studies show that the</p><p>lumbar arteries that feed the spine can get clogged with atherosclerosis and</p><p>starve the discs in the lower back of oxygen and nutrients.282</p><p>B is also for blood pressure. Excess visceral fat can physically compress</p><p>our kidneys,283 and the increased pressure can effectively squeeze sodium</p><p>back into our bloodstreams, increasing our blood pressures. Together, the</p><p>combination of obesity and hypertension can have “disastrous health</p><p>implications.”284 Ready for some good news? Even just a few pounds of</p><p>weight loss can help take off the pressure. Losing weight has been</p><p>described as a “vital strategy for controlling hypertension.”285 In fact, losing</p><p>around nine pounds was shown to lower blood pressures286 about as much</p><p>as cutting salt intake287 approximately in half.288</p><p>C Is for Cancer</p><p>As many as three-quarters of people surveyed were evidently unaware of</p><p>the link between obesity and cancer289 when in fact, based on a</p><p>comprehensive review of a thousand studies, excess body fat raises the risk</p><p>of most cancers, including esophageal, stomach, colorectal, liver,</p><p>gallbladder, pancreatic, breast, uterine, ovarian, kidney, brain, thyroid, and</p><p>bone marrow (multiple myeloma) cancers.290 Why? It could be due to the</p><p>chronic inflammation that comes with obesity 291 or the high insulin levels</p><p>due to insulin resistance.292 (Besides controlling blood sugars, insulin is a</p><p>potent growth factor that can promote tumor growth.293) In women, it could</p><p>also be the excess estrogen.294</p><p>After the ovaries shut down at menopause, fat takes over as the principal</p><p>site of estrogen production. This is why obese women have up to nearly</p><p>twice the estrogen levels circulating in their bloodstreams,295 which is</p><p>associated with increased risk of developing—and dying from—breast</p><p>cancer.296 A twenty-pound weight loss can reduce estrogen levels within the</p><p>breast by 24 percent.297 The data on prostate cancer aren’t as strong,298</p><p>though obesity is associated with increased risk of invasive penile cancer.299</p><p>One reason we’re confident the link between obesity and cancer is cause</p><p>and effect, and not just an indirect consequence of eating poorly, is because</p><p>when people lose weight—even just through bariatric surgery—their overall</p><p>risk of cancer goes down. Those experiencing a sustained loss of about</p><p>forty pounds after surgery went on to develop around one-third fewer</p><p>cancers over the subsequent decade or so, compared with a nonsurgical</p><p>control group of matched individuals who continued to slowly gain weight</p><p>over time.300 The exception is colorectal cancer.301</p><p>Colorectal cancer appears to be the only malignancy for which the risk</p><p>goes up after obesity surgery. After bariatric surgery, the rate of rectal</p><p>cancer death may triple.302 The rearrangement of anatomy involved in one</p><p>of the most common surgeries—gastric bypass—is thought to increase bile</p><p>acid exposure along the intestinal lining. This causes sustained pro-</p><p>inflammatory changes even years after the procedure, which are thought to</p><p>be responsible for the increased cancer risk.303 In contrast, losing weight by</p><p>dietary means has the potential to decrease obesity-related cancer risk</p><p>across the board.</p><p>D Is for Diabetes</p><p>As laid out in a consensus statement from the International Diabetes</p><p>Federation, obesity is considered the single most important risk factor for</p><p>the development of type 2 diabetes,304 which is now the leading cause of</p><p>kidney failure, lower-limb amputations, and adult-onset blindness.305</p><p>Ironically, many of the leading drugs used to treat diabetes, including</p><p>insulin itself, actually cause further weight gain, creating a vicious cycle.306</p><p>So, again, using lifestyle medicine to treat the underlying cause is not only</p><p>the safest, simplest, and cheapest route but also can be the most effective.</p><p>E Is for Encephalopathy</p><p>Encephalopathy means brain disease, and there are consistent data linking</p><p>obesity in middle age to higher risk of dementia later in life.307 Overweight</p><p>individuals have about one-third higher risk, and those who are obese in</p><p>midlife seem to have about 90 percent greater risk of becoming</p><p>demented.308 The risk isn’t just limited to future dysfunction, though. People</p><p>with excess body weight don’t appear to think as clearly at any age.</p><p>Obese individuals show broad impairments in what are called executive</p><p>functions of the brain, such as working memory, decision-making, planning,</p><p>cognitive flexibility, and verbal fluency.309 These play a critical role in</p><p>everyday life. People may think about their obesity and the resulting stigma</p><p>they experience as much as five times every hour,310 but the cognitive</p><p>deficits do not appear to arise just from being distracted by these thoughts.</p><p>There are actually structural brain differences between normal-weight and</p><p>overweight individuals.</p><p>A review entitled “Does the Brain Shrink as the Waist Expands?” noted</p><p>gray matter atrophy across all ages among those carrying excess body fat.311</p><p>This reduced brain volume correlates with the lower executive function.312</p><p>Compromised integrity of the rest of the brain, the white matter, has also</p><p>been shown, which suggests accelerated brain aging even in young adults</p><p>and children with obesity.313 This implies that there’s something about the</p><p>obesity itself that is affecting brain function, rather than a later clinical</p><p>consequence of corresponding conditions such as high blood pressure.314</p><p>Purported mechanisms for such executive dysfunction include inflammation</p><p>and oxidative stress, both related to obesity.315</p><p>Does weight loss improve cognitive function? Based on a meta-analysis</p><p>of twenty studies, mental performance across a variety of domains can be</p><p>significantly improved with even modest weight loss, though no studies</p><p>have yet been done to determine if this then translates into a normalization</p><p>of Alzheimer’s disease risk.316</p><p>F Is for Fertility</p><p>F is for fertility, or rather failed fertility. Overweight couples struggling to</p><p>have children “should be educated on the detrimental effects of fatness,”</p><p>one meta-analysis concluded, as weight loss is associated with an</p><p>improvement in pregnancy rates among infertile women.317 Men may also</p><p>suffer impaired fertility. The heavier a man is, the greater his risk of having</p><p>a low sperm count or being completely sterile.318 This in part may be</p><p>because of the effects of excess body fat on testosterone levels.</p><p>Fat isn’t the primary site of estrogen production only in postmenopausal</p><p>women but in men as well. There’s an enzyme in body fat that actually</p><p>converts testosterone into estrogen.319 Even going from obese to just</p><p>overweight could potentially raise testosterone levels in the blood of men</p><p>by 13 percent.320</p><p>A more dramatic cause of infertility in obese men is called hidden penis.</p><p>Also referred to in the medical literature as buried penis, concealed penis,</p><p>or inconspicuous penis, it occurs when excess fat in the pubic area</p><p>subsumes the male member. It’s also called trapped penis because the moist</p><p>enfolding skin can result in a chronic inflammatory dermatitis leading to</p><p>scarring and requiring surgical intervention.321 So F may also stand for Free</p><p>Willy.</p><p>G Is for Gallstones and GERD</p><p>What is the number-one digestive reason people are hospitalized?</p><p>Gallbladder attack. Every year, more than a million Americans are</p><p>diagnosed with gallstones, and about seven hundred thousand have to get</p><p>their gallbladders surgically removed.322 It’s a relatively safe procedure.323</p><p>Immediate complication rates tend to be under 5 percent, and the mortality</p><p>rate is only about one in a thousand.324 However, 10 percent of patients may</p><p>develop “post-cholecystectomy syndrome” with persistent gastrointestinal</p><p>symptoms weeks or months after their gallbladders are removed.325</p><p>What are gallstones made of? In 80 to 90 percent of cases, gallstones are</p><p>mostly just crystallized cholesterol, forming like rock candy in the</p><p>gallbladder.326 This was used to explain why some small, earlier studies</p><p>found that nonvegetarians had a higher incidence of gallstones given their</p><p>higher cholesterol levels,327 but the results from larger, more recent studies</p><p>are more equivocal.328,329 The biggest purported cause-and-effect risk</p><p>factor330 may be obesity,331 which increases risk as much as sevenfold.332</p><p>Ironically, rapid weight loss may also be a trigger of gallbladder attacks.</p><p>A half pound a day has been deemed the “upper limit for medically safe</p><p>weight loss” based on gallstone formation. Ultrasound studies found that</p><p>above that limit, the incidence of new stones can go from less than one in</p><p>two hundred a week up to one in thirty.333 To help prevent a gallstone attack,</p><p>you can increase your fiber intake. Not only is dietary fiber intake</p><p>associated with less gallbladder disease,334 but those placed on high-fiber</p><p>foods during a weight-loss regimen suffered significantly less gallbladder</p><p>sludging than those losing the same weight without the extra fiber.335</p><p>Fiber-rich food consumption can also decrease the risk of acid reflux</p><p>(Gastroesophageal Reflux Disease, or GERD). The excess abdominal</p><p>pressure due to obesity may push up acid into the throat, causing heartburn</p><p>and inflammation.336 The increased pressure on the abdominal organs</p><p>associated with obesity may also explain why overweight women suffer</p><p>from more vaginal prolapse,337 where organs such as the rectum push out</p><p>into the vaginal cavity.</p><p>H Is for Heart Disease</p><p>Of the four million deaths attributed to excess body weight every year</p><p>around the world, nearly 70 percent are due to cardiovascular disease.338 Is</p><p>it just because those people had been eating poorly? Genetic studies suggest</p><p>that people effectively randomized from conception to be heavier—just</p><p>based on their genes—do indeed have higher rates of heart disease and</p><p>stroke regardless of what they eat.339 So, if we lose weight, does our risk</p><p>drop?</p><p>The SOS trial, which stands for Swedish Obese Subjects, was the first</p><p>long-term controlled trial to compare the outcomes of thousands of bariatric</p><p>surgery patients to matched control subjects who started out at the same</p><p>weight but went the nonsurgical route. The control group maintained their</p><p>weights, whereas the surgical group maintained about a 20 percent weight</p><p>loss over the next ten to twenty years. Over that time, the surgical weight-</p><p>loss group not only developed 80 percent less diabetes but suffered</p><p>significantly fewer heart attacks and strokes, so, not surprisingly, they</p><p>significantly reduced their total mortality overall.340</p><p>I Is for Immunity</p><p>The SOS trial also found that those who lost weight got less cancer.341 This</p><p>may be because antitumor immunity appears to be affected by weight.</p><p>Natural killer cells are our immune systems’ first line of defense against</p><p>cancer cells (as well as many viral infections), and their function is severely</p><p>impaired by obesity. When obese individuals were randomized to a weight-</p><p>loss program, there was a significant reactivation of natural killer cell</p><p>function within just three months.342 However, the program involved an</p><p>exercise component, so it’s hard to tease out the impact of the weight loss</p><p>itself since physical activity alone can boost natural killer cell activity.343</p><p>On the other end of the spectrum, obesity is suspected to</p><p>be a causal risk</p><p>factor for the development of multiple sclerosis, an autoimmune disease.344</p><p>This suggests obesity is associated with the worst of both worlds when it</p><p>comes to immune function: underactivity when it comes to protecting</p><p>against cancer and infection, but overactivity when it comes to certain</p><p>inflammatory autoimmune conditions.345</p><p>J Is for Jaundice</p><p>Thanks to the obesity epidemic, nonalcoholic fatty liver disease (NAFLD)</p><p>is now the most common liver disorder in the industrialized world.346 Fat</p><p>doesn’t just end up in our bellies and thighs but inside some of our internal</p><p>organs. More than 80 percent of individuals with abdominal obesity may</p><p>have fatty infiltration into their livers,347 and in those with severe obesity,</p><p>the prevalence can exceed 90 percent.348 This can lead to inflammation,</p><p>scarring, jaundice, and, ultimately, cirrhosis and liver cancer.349 Currently,</p><p>the advanced form of NAFLD, nonalcoholic fatty hepatitis, is the leading</p><p>cause of liver transplants in American women, and men are expected to</p><p>catch up by 2020.350</p><p>K Is for Kidneys</p><p>Obesity is also one of the strongest risk factors for chronic kidney disease.</p><p>Our kidneys compensate for the metabolic demands of excess weight by</p><p>red-lining into what’s called hyperfiltration to deal with the extra workload.</p><p>The resulting increased pressure within the kidneys can damage the</p><p>sensitive organs and increase the risk of kidney failure over the long term.351</p><p>… and L, M, N, O, P Through Z</p><p>If we wanted to keep singing the alphabet of obesity-related health</p><p>concerns, L could be for diminished lung function,352 M for a cluster of risk</p><p>factors known as metabolic syndrome,353 and so on. There’s even an X—for</p><p>xiphodynia, pain at the tip of the bottom of the breastbone from being bent</p><p>outward by an expanding abdomen.354</p><p>Counting the Costs</p><p>Given the myriad health conditions associated with excess weight, medical</p><p>spending attributable to obesity is nearly $2,000 per person per year,355 with</p><p>obese workers with multiple complications costing companies up to</p><p>$10,000 more in health-care coverage compared to lean counterparts.356</p><p>Beyond just brazen discrimination, this actually may account for some of</p><p>the wage gap obese employees experience as companies try to make up for</p><p>these costs.357 Between health-care costs and diminished productivity in</p><p>terms of lost workdays, the total per capita lifetime costs of long-term</p><p>obesity have been estimated to exceed $200,000.358</p><p>Some estimates peg the current national cost of obesity at about $150</p><p>billion,359 with another $50 billion per year added by 2030 as our</p><p>increasingly heavy baby boomers continue to age.360 The Milken Institute</p><p>appraised the cost of obesity as a trillion-dollar drag on the economy,361</p><p>more than twice what we spend on national defense.362 Others diametrically</p><p>disagree, based on the morbid fact that obese individuals may not live as</p><p>long. Just as the medical costs of tobacco-related diseases may be more than</p><p>offset by the shortened survival of smokers, the lifetime health-care costs of</p><p>obese individuals may turn out to be lower because they are expected to die</p><p>so much sooner.363 So the true cost may be calculated in lives rather than</p><p>dollars.</p><p>Larger Than Life</p><p>Martin Luther King Jr. warned that “human progress is neither automatic</p><p>nor inevitable,”364 and the same may be true of the human life span.365 In</p><p>1850, life expectancy in the United States was less than forty years,366 but it</p><p>has steadily increased over the last two centuries,367 gaining about two years</p><p>per decade—until recently, that is. Longevity gains have faltered or even</p><p>reversed, and the greatest victims will be our children. Thanks to the</p><p>obesity epidemic, we may now be raising the first American generation to</p><p>live shorter lives than their parents.368</p><p>The downward trend in longevity is expected to accelerate as the current,</p><p>younger generation—who started out heavier from a younger age than ever</p><p>before—matures into adulthood. If the obesity epidemic continues</p><p>unchecked, current trends signal a potential “looming social and economic</p><p>catastrophe.”369 In the coming decades, some predict we may lose two to</p><p>five years—or more—of life expectancy in the United States. To put that</p><p>into perspective, a miracle cure for all forms of cancer would only add three</p><p>and a half years to the average American life span.370 In other words,</p><p>reversing the obesity epidemic might save more lives than curing cancer.</p><p>The Obesity Paradox</p><p>The evidence that being overweight increases our risk for debilitating</p><p>diseases like diabetes is considered indisputable, but, surprisingly, there is</p><p>controversy surrounding body weight and overall mortality.371 In 2013,</p><p>scientists from the Centers for Disease Control and Prevention (CDC)</p><p>published a meta-analysis in The Journal of the American Medical</p><p>Association suggesting that being overweight was actually advantageous.</p><p>Yes, grade 2 or grade 3 obesity, which is like being the average American’s</p><p>height, five foot six,372 and weighing about 215 pounds or more, was</p><p>associated with living a shorter life, but grade 1 obesity (about 185–215</p><p>pounds at the same height) was not. And, being overweight (155–185</p><p>pounds at average height) appeared to be protective compared to those who</p><p>were normal weight (115–155 pounds at five foot six). The overweight</p><p>individuals, with a BMI of 25–30, appeared to live the longest.373</p><p>Headline writers were giddy: “Being Overweight Can Extend Life,”</p><p>“Dreading Your Diet? Don’t Worry … Plump People Live LONGER,”374</p><p>and “Extra Pounds Mean Lower Chance of Death.”375 Not surprisingly, the</p><p>study ignited a firestorm of controversy in the public health community and</p><p>was called “ludicrous,”376 “flawed,” and “misleading.”377 The chair of</p><p>nutrition at Harvard lost his cool, calling it “really a pile of rubbish,”378</p><p>fearing the food industry might exploit the study in the same way the</p><p>petroleum industry misuses a manufactured controversy over climate</p><p>change.379</p><p>Public health advocates can’t just dismiss data they find inconvenient,</p><p>though. Science is science. But how could being overweight increase the</p><p>risk of life-threatening diseases, yet, at the same time, make you live</p><p>longer? This became known as the obesity paradox.380 The solution to the</p><p>puzzle appears to lie with two major sources of bias, the first being</p><p>confounding by smoking.381</p><p>As I’ll explore in the Amping AMPK section, the nicotine in tobacco can</p><p>lead to weight loss. So if you’re skinnier because you smoke, then it’s no</p><p>wonder you’d live a shorter life with a slimmer waist. The failure to control</p><p>for the effect of smoking in studies purporting to show an “obesity paradox”</p><p>leads to the dangers of obesity being “grossly underestimated.”382</p><p>The second major source of bias is reverse causality. Instead of lower</p><p>weight leading to life-threatening diseases, isn’t it more likely that life-</p><p>threatening diseases lead to lower weight? Conditions such as hidden</p><p>tumors, chronic heart or lung disease, alcoholism, and depression can all</p><p>cause unintentional weight loss months or even years before a diagnosis is</p><p>made.383 As we’ve discussed, it’s become normal to be overweight in this</p><p>country.384 People who are “abnormally” thin—that is, at an ideal weight—</p><p>could actually be taking care of themselves, but they also may be heavy</p><p>smokers, elderly and frail, or seriously ill with weight loss from their</p><p>disease.385</p><p>Deadweight</p><p>To put the obesity paradox issue to the test once and for all, the Global BMI</p><p>Mortality Collaboration was formed, reviewing data from more than ten</p><p>million people from hundreds of studies in dozens of countries—the largest</p><p>evaluation of BMI and mortality in history.386 To help eliminate bias, the</p><p>researchers omitted smokers and those with known chronic disease. They</p><p>then excluded the first five years of follow-up to try to remove from the</p><p>analysis those with undiagnosed conditions who had lost weight due to an</p><p>impending death. The results were clear: Being overweight or any grade of</p><p>obesity was associated with a</p><p>significantly greater risk of dying</p><p>prematurely.387 In fact, adjusting for those biases leads to “eliminating the</p><p>obesity paradox altogether.”388 In other words, the so-called obesity paradox</p><p>appears to be just a myth.389</p><p>Indeed, when intentional weight loss is actually put to the test, people</p><p>live longer. Bariatric surgery studies like the SOS trial show weight loss</p><p>reduces long-term mortality,390 and randomizing people to lose weight</p><p>through lifestyle changes shows the same.391 Losing a dozen pounds</p><p>through diet and exercise was found to be associated with a 15 percent drop</p><p>in overall mortality risk. Exercise alone may extend life span even without</p><p>weight loss,392 but there also appears to be a similar longevity benefit of</p><p>weight loss through dietary means alone.393</p><p>The Optimal BMI for Optimal Longevity</p><p>The largest studies in the United States394 and around the world395 found that</p><p>having a normal body mass index, a BMI of 20–25, is associated with the</p><p>longest life span. Putting together all the best available studies with the</p><p>longest follow-up, that can be narrowed down even further to a BMI of 20–</p><p>22.396 You can use this unisex chart to see what your optimal weight might</p><p>be based on your height:</p><p>So even within a “normal” BMI, the risk of developing chronic diseases,</p><p>such as type 2 diabetes, heart disease, and several types of cancer, starts to</p><p>rise toward the upper end, starting as low as a BMI of 21. BMIs of 18.5 and</p><p>24.5 are both considered within the normal range, but a BMI of 24.5 may be</p><p>associated with twice the heart disease risk compared to 18.5.397 The ideal</p><p>BMI appears to be between 20 and 22, confirmed in a study of an</p><p>“unusually slim cohort” from the Oxford Vegetarian Study.398</p><p>Just as there are gradations of risk within a normal BMI range, there is a</p><p>spectrum within obesity. Grade 3 obesity, characterized as having a BMI</p><p>greater than 40, can be associated with the loss of a decade of life or more.</p><p>At a BMI greater than 45, such as a five-foot-six person at 280 pounds, life</p><p>expectancy may shrink to that of a cigarette smoker.399</p><p>Health at Every Size™?</p><p>There are “obesity skeptics” who argue that the health consequences of</p><p>obesity are unclear or even greatly exaggerated. They are a motley bunch of</p><p>unlikely bedfellows, ranging from feminists, queer theorists, and new</p><p>ageists to “far right wing, pro-gun, pro-America websites where the idea</p><p>[is] that obesity alarmists are nanny-state communists who simply want to</p><p>stop us from having fun.”400</p><p>There are also many “fat activists” who try to downplay the risks of</p><p>obesity. The director of medical advocacy for the Council on Size and</p><p>Weight Discrimination routinely takes part in obesity conferences and</p><p>government panels on obesity. She is quoted as saying, “I’m not actually</p><p>particularly that interested in [health]” and “God, I hate science.”401 Unlike</p><p>activists who, for example, organized to raise consciousness to stamp out</p><p>the AIDS epidemic, the size-acceptance movement appears to have the</p><p>opposite goal, rallying for less public awareness and treatment of the</p><p>problem.402 (They do have good slogans, though: “We’re here, we’re</p><p>spheres, get used to it!”403) I’m all for fighting size stigma and</p><p>discrimination, but the adverse health consequences of obesity are an</p><p>established scientific fact. In a study of more than six hundred centenarians,</p><p>those one hundred years old and older, fewer than 2 percent of the women</p><p>and not a single one of the men were obese.404</p><p>Can’t you be fat but fit? There appears to be a rare subgroup of obese</p><p>individuals who don’t suffer the typical metabolic costs of obesity, such as</p><p>high blood pressure and high cholesterol.405 This raised the possibility that</p><p>there may be such a thing as “benign obesity.”406 It may just be a matter of</p><p>time before the risk factors develop.407 But even if they don’t develop,</p><p>followed long enough, even “metabolically healthy” obese individuals are</p><p>at increased risk of diabetes,408 fatty liver disease,409 cardiovascular events</p><p>such as heart attacks, and/or premature death.410 Bottom line? There is</p><p>strong evidence that “healthy obesity” is a myth.411</p><p>Hating Their Guts</p><p>The size-acceptance movement is definitely right about one thing, though:</p><p>the extraordinary scourge of weight stigma. Described as the last</p><p>“acceptable” form of bias,412 weight stigma is the rampant discrimination</p><p>and stereotyping of overweight individuals. Fifty overweight women were</p><p>asked to keep a diary of all the times they felt they were stigmatized for</p><p>their weights. Over just one week, more than a thousand instances were</p><p>recorded.413 An overweight woman may expect to be harassed (such as</p><p>called names or insulted), encounter physical barriers (like being unable to</p><p>fit into public seats), or be discriminated against (such as receiving</p><p>perceived poorer service at restaurants or stores) on average about three</p><p>times a day. Obese men report three times less discrimination than women</p><p>of the same size,414 so it may be only a daily occurrence for them.</p><p>This weight stigma starts surprisingly early. Children as young as three</p><p>years old label overweight peers as “mean,” “stupid,” “lazy,” and “ugly.”415</p><p>One of the most poignant illustrations comes from a famous study</p><p>published in 1961. Children in summer camps and schools across a swath of</p><p>different social, cultural, and ethnic backgrounds in California, Montana,</p><p>and New York were asked to rank the following images as to whom they</p><p>liked best:</p><p>1. a child in crutches with one leg in a brace</p><p>2. a child in a wheelchair</p><p>3. a child with one hand missing</p><p>4. a facially disfigured child</p><p>5. an obese child</p><p>In every population of kids they tested, there was “remarkable</p><p>uniformity.”416 The obese child always came in dead last.</p><p>But that was ages ago. What happened when the original study was</p><p>repeated? Researchers published the forty-year follow-up in 2003, and</p><p>guess what they found? The title of the study gives it away: “Getting</p><p>Worse: The Stigmatization of Obese Children.” The obese child was liked</p><p>even less.417 This parallels trends throughout society with a 70 percent jump</p><p>in perceived weight discrimination recorded in national surveys since the</p><p>mid-1990s.418</p><p>Attitudes among educators may not be helping. More than a quarter of</p><p>teachers and other school staff surveyed felt that becoming obese is “one of</p><p>the worst things that could happen to a person.”419 Even parents can be</p><p>biased, providing less support for college for their overweight daughters</p><p>compared to thinner siblings.420 As two prominent obesity researchers</p><p>commented, “It is strong prejudice indeed when parents discriminate</p><p>against their own children.”421</p><p>What about doctors? One representative national survey found that more</p><p>than half of physicians viewed obese patients as “awkward, unattractive,</p><p>ugly, and noncompliant.”422 About a quarter of nurses agreed or strongly</p><p>agreed with the statement “Caring for an obese patient usually repulses</p><p>me.”423 This antagonism can have serious health consequences for those</p><p>who may need care the most. For example, obese women are at higher risk</p><p>for developing cervical,424 endometrial, and ovarian cancers,425 yet they are</p><p>less likely to be screened. Morbidly obese patients only have about half the</p><p>odds of getting their recommended pelvic exams.426 Though some of this</p><p>may be avoidance on the part of the patient, some doctors just turn away</p><p>obese patients. The Sun Sentinel polled OB-GYN practices in Florida and</p><p>found that as many as one in seven refused to see heavier women, for</p><p>example, setting weight cutoffs for new patients starting at two hundred</p><p>pounds.427</p><p>Even doctors who welcome obese patients have been found to give them</p><p>short shrift. Physicians randomized to receive a medical chart of a migraine</p><p>patient who either presented as average weight or obese said they would</p><p>give the obese patient about 28 percent less of their time428—and it’s less</p><p>quality time too. Recorded doctor visits found physicians tend to build less</p><p>emotional rapport with overweight patients.429</p><p>At least the</p><p>doctors appear able to hide their disdain. In a study entitled</p><p>“Obese Patients Overestimate Physicians’ Attitudes of Respect,” despite the</p><p>negative attitudes doctors harbored toward their obese patients, the same</p><p>patients expressed their satisfaction with their providers. The researchers</p><p>concluded, “While physicians may be successfully playing the part, the lack</p><p>of true respect suggests … the authenticity of the patient–physician</p><p>relationship should be questioned.”430</p><p>For Shame</p><p>Weight stigma may perpetuate a cycle of stress leading to obesity, leading</p><p>to even more stress. I discuss this concept further in the Stress Hormone</p><p>Relief section. Across thousands of individuals followed for four years,</p><p>those reporting discriminatory experiences had more than twice the odds of</p><p>becoming obese. As well, those who started out obese had more than three</p><p>times the odds of staying that way compared to people who started out at</p><p>the same weight but didn’t experience discrimination.431 This could be from</p><p>stress-induced eating on one side of the calorie-balance equation or stigma-</p><p>induced exercise avoidance on the other.</p><p>Obese individuals with more frequent experiences with weight stigma</p><p>report greater avoidance of exercising in public, feeling judged and</p><p>embarrassed.432 These “too fat to exercise”433 fears may be well grounded.</p><p>Strong anti-fat biases have been documented in both fitness professionals</p><p>and regular gym-goers,434 which may present an unwelcoming environment</p><p>in fitness centers and health clubs.435</p><p>Whichever side of the calorie equation gets tipped, those who experience</p><p>weight stigma can end up suffering health consequences independent of any</p><p>added weight. Those reporting more frequent fat prejudice exhibit higher</p><p>levels of depression,436 inflammation,437 and oxidative stress,438 as well as</p><p>shorter life spans. Two studies following a total of nearly twenty thousand</p><p>people both found about a 50 percent increase in mortality risk among those</p><p>reporting greater daily discrimination.439 Despite these hazards, some</p><p>scholars advocate for even more fat shaming.</p><p>The president emeritus of the prestigious Hastings Center infamously</p><p>advocated for “a kind of stigmatization lite,” using social pressures to</p><p>compel people to lose weight without resorting to outright discrimination.</p><p>After all, he argued, what else has the potential to counter the persuasive</p><p>force of the billions spent in advertising every year by the food and</p><p>beverage industry? It worked against tobacco. He recalls his own battle</p><p>with addiction: “The force of being shamed and beat upon socially was as</p><p>persuasive for me to stop smoking as the threats to my health.” The public</p><p>health campaign to stigmatize cigarettes turned what had been considered</p><p>“simply a bad habit into reprehensible behavior.”440</p><p>When such campaigns have been tried, they have been met with fierce</p><p>resistance. Georgia’s Strong4Life campaign featured billboards of morose-</p><p>looking obese children with such captions as “Warning: Chubby kids may</p><p>not outlive their parents” and “It’s hard to be a little girl when you’re</p><p>not.”441 The campaign sponsors defended the ads as an attempt to break</p><p>through the denial in a state with some of the highest recorded childhood</p><p>obesity rates442—but it’s only defensible if it works.</p><p>So does it? Being labeled “too fat” in childhood was associated with a</p><p>higher risk of becoming obese compared to children who weighed the same</p><p>but were never told that.443 Does this mean we should just ignore the</p><p>elephant in the room? Many doctors apparently think so.</p><p>Just as veterinarians have been found to be reluctant to tell people their</p><p>pets are obese,444 many pediatricians are similarly quiet when it comes to</p><p>discussing weight concerns with parents. Less than a quarter of parents of</p><p>overweight children report having been told that about their children’s</p><p>weight status by their pediatricians.445 One might think it would be obvious,</p><p>but a Gallup survey found that parents appear to be “notoriously poor</p><p>judges of their children’s weight.” Similarly, despite skyrocketing obesity,</p><p>the percentage of adults who describe themselves as overweight has</p><p>remained essentially unchanged over the past few decades. All this, Gallup</p><p>concluded, helps “paint a picture of mass delusion in the United States</p><p>about its rising weight.”446</p><p>I think patients have the right to be informed. Those told by their doctors</p><p>that they are overweight have nearly four times the odds of attempting</p><p>weight loss447 and about twice the odds of succeeding.448 Just as physicians</p><p>who smoke are less likely to challenge their patients who smoke,</p><p>overweight physicians are less likely to bring up the subject of weight</p><p>loss449 or even document obesity in patient charts.450 Ironically, overweight</p><p>patients trust diet advice more from overweight doctors than those who are</p><p>normal weight.451</p><p>As obesity rates have gone up, the rate of weight counseling advice from</p><p>primary care physicians has inexplicably gone down.452 Even when they do</p><p>manage to counsel patients, doctors appear to have little to offer in terms of</p><p>specifics. Fewer than half who were surveyed said they provide specific</p><p>guidance to their patients.453 Just telling patients Watch what you eat, is</p><p>unlikely to be particularly helpful, but many primary care physicians may</p><p>not even go that far. Physical inactivity was rated by physicians as</p><p>significantly more important than any other cause of obesity, which is far</p><p>from accurate, as I discuss here. Most physicians said they would spend</p><p>more time working with patients on weight management if only their time</p><p>were “reimbursed appropriately.”454 Maybe we could even offer doctors a</p><p>bonus to refrain from blaming the victim.455 As one pair of commentators</p><p>wrote in response to the pro-stigmatization camp, “If shaming reduced</p><p>obesity, there would be no fat people.”456</p><p>Blind, Deaf, Dumb, or Fat</p><p>I want to end this stigma section with the jaw-dropping findings of a study I</p><p>think best illustrates how hard it is to live inside a fat body. If this doesn’t</p><p>foster sympathy among my medical colleagues, I don’t know what will.</p><p>Researchers talked with men and women who had lost and kept off more</p><p>than 100 pounds to tap into their unique insights, having personally</p><p>experienced what it was like to be morbidly obese and then, on average,</p><p>126 pounds lighter. Forty-seven such individuals were interviewed.</p><p>They were asked to think back to when they were heavier and make a</p><p>choice: “If someone offered you a couple of million dollars if you stayed</p><p>morbidly obese forever, would you have chosen the money? Or would you</p><p>have chosen to be normal weight no matter what?”</p><p>Option 1: “I would have chosen no money and being normal weight.</p><p>It would have taken me one second to decide.”</p><p>Option 2: “I probably would have chosen being normal weight. But</p><p>the possibility of having that much money would make me think about</p><p>the choice.”</p><p>Option 3: “I wanted to be normal weight, but I really could use the</p><p>money. If I would be a multimillionaire I think I could live with being</p><p>morbidly obese.”</p><p>One of the forty-seven people had to think about it, but the other forty-</p><p>six jumped at Option 1. Not a single person chose Option 3. They all said</p><p>they would give up being a multimillionaire to be normal weight.457</p><p>If that shocked you, buckle your seat belt. They were then asked about</p><p>being obese compared to other disabilities. Normally when you ask people</p><p>to choose between living with their own disability or switching to a</p><p>different one, there is a strong proclivity to stay with their own.458 For</p><p>example, even though most people would rather be deaf than blind, blind</p><p>people prefer to remain blind by a large margin rather than having sight</p><p>without sound. They already know how to cope with their own disability, so</p><p>there’s safety in familiarity. The exact opposite happened when the formerly</p><p>obese were asked.</p><p>Each of the forty-seven men and women said they’d rather be deaf for</p><p>the rest of their lives than obese. Every single one said they’d rather be</p><p>unable to read,</p><p>be diabetic, have very bad acne, or have heart disease than</p><p>be obese. And then the true jaw-dropper: More than 90 percent said they’d</p><p>rather have a leg amputated, and, similarly, about nine out of ten said they’d</p><p>rather be blind their whole lives than obese. Obesity appears to be the only</p><p>handicap where nearly everyone wants to switch disabilities no matter what</p><p>the cost. To quote one study subject, “When you’re blind, people want to</p><p>help you. No one wants to help when you’re fat.”459</p><p>How Much Weight Does It Take?</p><p>We seem to have become inured to the mortal threat of obesity. If you go</p><p>back in the medical literature a half century or so, when obesity wasn’t run</p><p>of the mill, the descriptions are much grimmer: “Obesity is always tragic,</p><p>and its hazards are terrifying.”460 But it doesn’t have to be frank obesity. Of</p><p>the four million deaths every year attributed to excess body fat, nearly 40</p><p>percent of the victims are just overweight, not obese.461 According to two</p><p>famous Harvard studies, as little as eleven pounds of weight gain from early</p><p>adulthood through middle age increases the risk of major chronic disease.462</p><p>The flip side is that even modest weight loss can have major health</p><p>benefits.</p><p>The good news is the riskiest fat is the easiest to lose. Our bodies appear</p><p>to preferentially shed the villainous visceral fat first.463 Although it may take</p><p>losing as much as 20 percent of your weight to realize significant</p><p>improvements in quality of life for most individuals with severe obesity,464</p><p>disease risk drops almost immediately. At 3 percent weight loss (only six</p><p>pounds for someone weighing two hundred), your blood sugar control and</p><p>triglycerides start to get better.465 At 5 percent weight loss, blood pressure</p><p>and cholesterol improve. Furthermore, a 5 percent weight loss—just ten</p><p>pounds for someone starting at two hundred—may cut the risk of</p><p>developing diabetes in half.466</p><p>What About Weight Cycling?</p><p>There was a book originally published in the 1980s and then repeatedly</p><p>republished ever since entitled Dieting Makes You Fat. Since most people</p><p>who lose weight go on to regain it, the concern is there may be adverse</p><p>health effects to so-called yo-yo dieting.467 This idea emerged from animal</p><p>studies468 that showed, for example, detrimental effects of starving and</p><p>refeeding obese rats.469 This captured the media’s attention, leading to a</p><p>pervasive common belief about the “dangers” of weight cycling,</p><p>discouraging people from even trying.470</p><p>Even the animal data are inconclusive, though. For example, weight</p><p>cycling mice makes them live longer.471 Most importantly, other than</p><p>perhaps a greater risk of gallstones,472,473 a review of the human data</p><p>concluded that “evidence for an adverse effect of weight cycling appears</p><p>sparse, if it exists at all.”474 In fact, as I write this, the current issue of</p><p>Obesity, the official journal of the leading scientific society dedicated to the</p><p>field, published a commentary entitled “Yo-Yo Dieting Is Better Than</p><p>None.”475</p><p>The Skinny on Fat</p><p>Let’s take a closer look at the best way to measure and define excess body fat.</p><p>BODY MASS INDEX VS. BODY FAT PERCENTAGE</p><p>Most of the population studies that have explored the relationship between obesity and disease</p><p>have relied on BMI,476 body mass index. (Calculate your own here.) BMI takes height into</p><p>account but doesn’t take the composition of the weight into account. Bodybuilders are heavy</p><p>for their heights but can be extremely lean. The gold-standard measure of obesity is</p><p>percentage of body fat,477 but accurate calculations for this can be complicated and</p><p>expensive.478 All that’s needed to measure BMI is a scale and a tape measure, but it may</p><p>underestimate the true prevalence of obesity.</p><p>The World Health Organization479 and the American College of Endocrinology480 define</p><p>obesity as a body fat percentage over 25 percent in men or 35 percent in women. At a BMI of</p><p>25, which is considered just barely overweight, body fat percentages in a representative U.S.</p><p>sample of adults varied between 14 and 35 percent in men and 26 and 43 percent in</p><p>women.481 So you could be normal weight, but actually obese.482 Using the BMI cutoff for</p><p>obesity, only about one in five Americans were obese back in the 1990s, but based on their</p><p>body fat, the true proportion back then was closer to 50 percent.483 Even by the ’90s, half of</p><p>America was not just overweight but obese.</p><p>By using only BMI, doctors may misclassify more than half of obese individuals as being</p><p>just overweight or even normal weight and miss an opportunity to intervene.484 The important</p><p>thing, however, is not the label but the health consequences. Ironically, BMI appears to be an</p><p>even better predictor of cardiovascular disease death than body fat percentage.485 This</p><p>suggests that excess weight from any source—fat or lean—may not be healthy in the long</p><p>run.486 The life spans of professional bodybuilders do seem to be cut short. They have about a</p><p>third higher mortality rate than the general population, with an average age of death around</p><p>forty-eight years,487 but this may be due in part to the toxic effects of anabolic steroids on the</p><p>heart.488</p><p>WEIGHT VS. WAIST</p><p>Preeminent nutritional physiologist Ancel Keys (after whom K rations were named489)</p><p>suggested the mirror method: “If you really want to know whether you are obese, just undress</p><p>and look at yourself in the mirror. Don’t worry about our fancy laboratory measurements;</p><p>you’ll know!”490 All fat is not the same, though. There is the pinchable, superficial flab you</p><p>may see jiggling about your body, and then there’s the riskier, visceral fat that coils around</p><p>and infiltrates your internal organs, bulging out your belly.491 Measuring BMI is simple,</p><p>cheap, and effective, but it doesn’t take into account the distribution of fat on the body—</p><p>whereas waist circumference can provide a measure of the deep underlying abdominal fat.</p><p>Both BMI and waist circumference can be used to predict the risk of death due to excess</p><p>body fat,492 but even at the same BMI, there appears to be nearly a straight-line increase in</p><p>mortality risk with widening waistlines.493 Someone with “normal-weight central obesity”—</p><p>meaning someone not even considered to be overweight according to BMI, but who carries fat</p><p>around the middle494—may have up to twice the risk of dying compared to someone who’s</p><p>overweight or obese according to their weight and height. This is why the World Health</p><p>Organization,495 National Institutes of Health,496 and American Heart Association497</p><p>recommend measuring both BMI and waist circumference. This may be especially important</p><p>for older women, who lose approximately 13 pounds of bone and muscle as they age from</p><p>twenty-five to sixty-five, while quadrupling their visceral fat stores. (Men’s visceral fat stores</p><p>tend only to double.)498 So even if a woman doesn’t gain any weight according to the</p><p>bathroom scale, she may be gaining fat.</p><p>What’s the healthy waistline cutoff? 499 Increased risk of metabolic complications starts at</p><p>an abdominal circumference of 31.5 inches in women and 37 inches in most men, but closer to</p><p>35.5 inches for Chinese, Japanese, and South Asian men.500 The benchmark for substantially</p><p>increased risk starts at about 34.5 inches for women and 40 inches for men.501 Once you get</p><p>greater than an abdominal circumference of about 43 inches in men, mortality rates shoot up</p><p>about 50 percent compared to men with 8-inch-smaller stomachs, and women suffer 80</p><p>percent greater mortality risk at 37.5-inch waists compared to 27.5 inches.502 The reading of a</p><p>measuring tape may translate into years off one’s life span.</p><p>Surprisingly, there is no universal protocol for assessing waist circumference. Some</p><p>guidelines recommend measuring at the level of the last rib, others at the top of the hip bones,</p><p>and others still suggest halfway between those landmarks, or at the belly button, or at the</p><p>narrowest point.503 While the belly button may be the most intuitive and easiest to measure</p><p>(and the preferred location for a one-time visceral fat assessment),504</p><p>the halfway point</p><p>between the top of the hip bones and bottom of the rib cage appears to be the most effective at</p><p>tracking changes in visceral fat over time.505</p><p>KEEP YOUR WAIST LESS THAN HALF YOUR HEIGHT</p><p>Unlike waist circumference, body mass index has the advantage of taking height into account.</p><p>Waist-to-height ratio may offer the best of both worlds, and the cutoff value is the simplest to</p><p>remember: Keep your waist less than half your height.506 The goal for adults and children six</p><p>years or older is to get a waist-to-height ratio under 0.5.507</p><p>Waist-to-height ratio may be a better predictor of both body fat percentage and visceral fat</p><p>mass than BMI or waist circumference alone.508 In terms of screening for cardiometabolic</p><p>risk (for example, heart disease and diabetes), waist-to-height ratio appears superior to BMI in</p><p>adults509 and seems to work as well as BMI for assessing body fat in children.510 So the ideal</p><p>may be a combination of BMI and a measure of abdominal obesity, such as waist-to-height</p><p>ratio.511</p><p>THE SOLUTIONS</p><p>Bringing a Butter Knife to a Gunfight</p><p>Now that you have a sense of the causes and consequences of obesity, let’s</p><p>look at the panoply of solutions that have been undertaken to combat excess</p><p>body fat—and whether or not they actually address the root cause. The</p><p>treatment of obesity has long been stained by the snake-oil swindlings of</p><p>profiteers, hustlers, and quacks. Even the modern field of bariatric medicine</p><p>(derived from the Greek word baros, meaning weight) is pervaded by an</p><p>“insidious image of sleaze.”512 Beguiled by advertising for fairy-tale magic</p><p>bullets of rapid, effortless weight loss, people blame themselves for failing</p><p>to manifest the miracle or imagine themselves to be metabolically broken.</p><p>On the other end of the spectrum are overly pessimistic practitioners of the</p><p>opinion that “people who are fat are born fat, and nothing much can be done</p><p>about it.”513 The truth lies somewhere in between.</p><p>The difficulty of curing obesity has been compared to learning a foreign</p><p>language; it’s an achievement virtually anyone can attain with a sufficient</p><p>investment of energies, but it always takes considerable time and effort.514</p><p>Research suggests that most obese individuals don’t stay in treatment. Of</p><p>those who do, most don’t adhere to it sufficiently to lose the excess weight.</p><p>But, even among those who try to stick with it, most will regain much of the</p><p>weight.515 To me, this speaks to the difficulty, rather than the futility. It may</p><p>take smokers an average of thirty quit attempts to finally kick the habit.516</p><p>Like quitting smoking, it helps to think of losing excess weight as just</p><p>something that has to be done. As the chair of the Association for the Study</p><p>of Obesity put it, it doesn’t take willpower to do essential tasks like getting</p><p>up at night to feed a baby—it’s just something that has to be done.517</p><p>Our collective response to the obesity epidemic doesn’t seem to match</p><p>the rhetoric or reality.518 If obesity is such a “national crisis” “reaching</p><p>alarming proportions,”519 dubbed by the post-9/11 Surgeon General as</p><p>“every bit as devastating as terrorism,” why has our reaction been so tepid?</p><p>520 For example, governments meekly suggest the food industry take</p><p>“voluntary initiatives to restrict the marketing of less healthy food options</p><p>to children.”521 Have we just given up and ceded control to Big Business?</p><p>Our timid response to the obesity epidemic is encapsulated by a national</p><p>initiative promulgated by the Joint Task Force of the American Society for</p><p>Nutrition, Institute of Food Technologists, and International Food</p><p>Information Council: the “small-changes approach.”522 Since small changes</p><p>are “more feasible,”523 suggestions include “using mustard rather than</p><p>mayonnaise” and “eating 1 rather than 2 doughnuts in the morning.”524</p><p>Seems a bit like bringing a butter knife to a gunfight. Proponents of the</p><p>small-changes approach lament that unlike other addictions, such as</p><p>alcohol, cocaine, gambling, or tobacco, we can’t counsel our obese patients</p><p>to give up the addictive element completely, as “no one can give up</p><p>eating.”525 But just because we have to breathe doesn’t mean it has to be</p><p>through the end of a cigarette. Similarly, just because we have to eat doesn’t</p><p>mean we have to eat junk.</p><p>Bariatric Surgery</p><p>Liposuction Sucks</p><p>The first surgical attempt at body fat sculpting was in 1921. A dancer</p><p>wanted to “improve” the shape of her ankles. The surgeon apparently</p><p>scraped away too much tissue and tied the stitches too tight, resulting in</p><p>necrosis, amputation, and the first recorded malpractice suit in the history of</p><p>plastic surgery.526 Modern liposuction is much safer, killing only about one</p><p>in five thousand patients.527</p><p>Liposuction currently reigns as the most popular cosmetic surgery in the</p><p>world, and its effects are indeed only cosmetic.528 A study published in The</p><p>New England Journal of Medicine assessed fifteen obese women before and</p><p>after having about twenty pounds of fat sucked out of their bodies, resulting</p><p>in nearly a 20 percent drop in their total body fat.529 Normally, if you lose</p><p>even just 5–10 percent of your body weight in fat, you get significant</p><p>improvements in blood pressure, blood sugars, inflammation, cholesterol,</p><p>and triglycerides,530 but none of those benefits materialized after the</p><p>massive liposuction.531</p><p>This suggests subcutaneous fat, the fat under our skin, is not the</p><p>problem. The metabolic insults of obesity arise from the visceral fat</p><p>surrounding or even infiltrating our inner organs, like the fat marbling our</p><p>muscles and livers. The way you lose that fat, the dangerous fat, is to take</p><p>in fewer calories than you burn.</p><p>Under the Knife</p><p>What about bringing a scalpel to the gunfight instead? The use of bariatric</p><p>surgery has exploded from about forty thousand procedures per year, as</p><p>noted in the first international survey in 1998,532 to hundreds of thousands</p><p>now performed each year in the United States alone.533 The first technique</p><p>developed, the intestinal bypass, involved carving out about twenty feet of</p><p>intestines.534,535 More than thirty thousand intestinal bypass operations were</p><p>performed536 before the “catastrophic,”537 “disastrous outcomes” were</p><p>recognized.538 This included protein deficiency–induced liver disease539</p><p>progressing to “fatal hepatic necrosis.”540 Its inauspicious start is</p><p>remembered as “one of the dark blots in the history of surgery.”541</p><p>Today, death rates after bariatric surgery are considered “very low,”</p><p>occurring on average in perhaps one in three hundred542 to one in five</p><p>hundred patients.543 The most common procedure is stomach stapling, also</p><p>known as a sleeve gastrectomy, in which most of the stomach is</p><p>permanently removed,544 leaving only a narrow sleeve or tube of stomach so</p><p>as to restrict how much food people can eat at any one time.545 It’s ironic</p><p>that many patients choose bariatric surgery, convinced that “diets don’t</p><p>work” for them, when, in reality, that’s all the surgery may be—an enforced</p><p>diet.546 Bariatric surgery can be thought of as a form of internal jaw wiring.</p><p>Gastric bypass is the second most common bariatric surgery.547 It</p><p>combines restriction—stapling the stomach into a pouch smaller than the</p><p>size of a golf ball—with malabsorption, by rearranging our anatomy to</p><p>bypass the first part of our small intestines.548 It appears to be more effective</p><p>than just cutting out most of the stomach—resulting in a loss of 63 percent</p><p>of excess weight compared to 53 percent with a gastric sleeve549—but</p><p>gastric bypass carries a greater risk of serious complications.550 Many are</p><p>surprised to learn that new surgical procedures don’t require premarket</p><p>testing or approval by the Food and Drug Administration (FDA)551 and are</p><p>largely exempt from rigorous regulatory scrutiny,552 potentially making new</p><p>surgeries even riskier than new medications.</p><p>It’s Complicated</p><p>The third most common bariatric procedure is a revision to fix a previous</p><p>bariatric procedure.553 Up to 25 percent of bariatric patients have to go back</p><p>into the</p><p>operating room to rectify problems caused by their first bariatric</p><p>surgery or for additional procedures. Reoperations are riskier, carrying up to</p><p>ten times the mortality rate,554 and offer no guarantee of success.555</p><p>Complications include leaks,556 fistulas, ulcers, strictures, erosions,</p><p>obstructions, and severe acid reflux.557</p><p>The extent of risk may depend on the skill of the surgeon. In a study</p><p>published in The New England Journal of Medicine, bariatric surgeons</p><p>voluntarily submitted videos of themselves performing surgery to a panel of</p><p>their peers for evaluation. Technical proficiency varied widely and was</p><p>related to the rates of complications, hospital readmissions, reoperations,</p><p>and death. Patients operated on by the less competent surgeons suffered</p><p>nearly three times the complications and five times the risk of death.558</p><p>As with athletes and musicians, some surgeons may simply be more</p><p>talented than others, but practice may help make perfect.559 Gastric bypass</p><p>is such a complicated procedure that its learning curve may require</p><p>hundreds of cases for a surgeon to master it. Risk of complications plateaus</p><p>after about five hundred cases, with the lowest risk found among surgeons</p><p>who’ve performed more than six hundred bypasses.560 So if you do choose</p><p>to undergo the procedure, I’d recommend asking your surgeon how many</p><p>they’ve done and also choosing an accredited Bariatric Center of</p><p>Excellence, since surgical mortality appears to be two to three times lower</p><p>at those institutions than at nonaccredited ones.561</p><p>Even if the surgery goes perfectly, lifelong nutritional replacement and</p><p>monitoring are required to avoid vitamin and mineral deficits562—the</p><p>consequences of which include more than just a little anemia, osteoporosis,</p><p>or hair loss.563 Bariatric surgeries have resulted in full-blown cases of</p><p>potentially life-threatening deficiencies, such as beriberi, pellagra,</p><p>kwashiorkor, and nerve damage564 that can manifest as vision loss years or</p><p>even decades after surgery (in the case of copper deficiency).565 Tragically,</p><p>in cases of severe deficiency of a B vitamin called thiamine, nearly one in</p><p>three patients progressed to permanent brain damage before they were even</p><p>diagnosed.566</p><p>The malabsorption of nutrients is on purpose for procedures like gastric</p><p>bypass. By cutting out segments of the intestine, we can successfully impair</p><p>the absorption of calories—but at the expense of impairing the absorption</p><p>of necessary nutrition. Even people who simply undergo restrictive</p><p>procedures like stomach stapling can be at risk for life-threatening nutrient</p><p>deficiencies because of persistent vomiting.567 Indeed, vomiting is reported</p><p>by up to 60 percent of patients after bariatric surgery due to “inappropriate”</p><p>eating behaviors—that is, by trying to eat normally.568</p><p>“Dumping syndrome” can work the same way. A large percentage of</p><p>gastric bypass patients can suffer from abdominal cramps, diarrhea, nausea,</p><p>bloating, fatigue, or palpitations after eating calorie-rich foods as they</p><p>bypass the stomach and dump straight into the intestines. As surgeons</p><p>describe it, this is a feature, not a bug: “Dumping syndrome is an expected</p><p>and desired part of the behavior modification caused by gastric bypass</p><p>surgery; it can deter patients from consuming energy-dense food.”569</p><p>Bariatric Surgery: Metabolic or Hyperbolic?</p><p>The surgical community objects to the characterization of bariatric surgery</p><p>as internal jaw wiring, the cutting up of healthy organs just to discipline</p><p>people’s behavior. The field has gone as far as to rename it “metabolic</p><p>surgery,” suggesting the anatomical rearrangements cause changes in</p><p>digestive hormones that offer unique physiological benefits.570 As evidence,</p><p>the surgical community points to the remarkable remission rates for type 2</p><p>diabetes.</p><p>After bariatric surgery, about 55 percent of obese diabetics and 75</p><p>percent of “super-obese” diabetics go into remission, meaning they have</p><p>normal blood sugars off all diabetes medications.571 The normalization in</p><p>blood sugars can happen within just days after the surgery.572 Fifteen years</p><p>after surgery, 30 percent may remain diabetes-free (compared to a 7 percent</p><p>cure rate in a nonsurgical control group).573 But are we sure it was the</p><p>surgery that did this? Could their improvement in blood sugars just be from</p><p>the extreme caloric restriction that typically precedes and also follows</p><p>surgery, rather than some surgical sort of metabolic magic? Researchers</p><p>decided to put it to the test.</p><p>At a bariatric surgery clinic at the University of Texas, patients with type</p><p>2 diabetes scheduled for a gastric bypass volunteered to first undergo an</p><p>identical period of caloric restriction. They were placed in the hospital and,</p><p>for ten days, were put on the same diet they would be on immediately</p><p>before and after the surgery, averaging fewer than five hundred calories a</p><p>day to mimic the surgical situation. The researchers then waited a few</p><p>months so the subjects would gain back the weight before putting them</p><p>through the actual surgery, matched day for day to the diets they had been</p><p>on before. Same patients, same diets—just with or without the actual</p><p>surgery. If there were some sort of metabolic benefit to the anatomical</p><p>rearrangement, they would have done better with the actual surgery, but in</p><p>some ways, they actually did worse. The caloric restriction alone resulted in</p><p>similar improvements in blood sugar, pancreatic function, and insulin</p><p>sensitivity, but several measures of diabetic control improved significantly</p><p>more without the surgery.574 So, if anything, the surgery seemed to put them</p><p>at a metabolic disadvantage.</p><p>The bottom line is that type 2 diabetes is reversible with weight loss if</p><p>you catch it early enough. With the loss of 15 percent of body weight,</p><p>nearly 90 percent of those who’ve had type 2 diabetes for fewer than four</p><p>years can achieve remission, whereas it may only be reversible in 50</p><p>percent of those who’ve lived with the disease for longer than eight years.575</p><p>That’s losing weight with diet alone, though. The remission numbers for</p><p>diabetics losing more than twice as much weight with bariatric surgery may</p><p>only be around 62 percent and 26 percent, respectively.576 So losing weight</p><p>with your fork can be more than twice as effective as the surgeons’ knives.</p><p>Losing weight without resorting to surgery may offer other benefits as</p><p>well. In the Anti-Inflammatory section, I’ll discuss the slimming hormone</p><p>leptin. Losing weight with diet alone can improve leptin sensitivity,577 but</p><p>losing weight from gastric bypass apparently does not.578 Diabetics losing</p><p>weight with diet alone can also improve markers of systemic inflammation,</p><p>such as tumor necrosis factor, whereas levels significantly worsened when</p><p>about the same amount of weight was lost from a gastric bypass.579</p><p>The Blind Leading the Blind</p><p>What about diabetic complications? Two of the reasons we don’t want</p><p>diabetes are that we don’t want to go blind and we don’t want to go on</p><p>dialysis. Reversing diabetes with bariatric surgery can improve kidney</p><p>function580 but, surprisingly, may not prevent the appearance581 or</p><p>progression of diabetic vision loss.582 Perhaps this is because bariatric</p><p>surgery affects diet quantity but not necessarily diet quality. This reminds</p><p>me of a famous study published in The New England Journal of Medicine</p><p>that randomized thousands of diabetics to an intensive lifestyle program</p><p>that focused on weight loss. Ten years in, the study was stopped</p><p>prematurely because the diabetics weren’t living any longer or having any</p><p>fewer heart attacks.583 This may be because they remained on the same</p><p>heart-clogging diet, but just with smaller portions.</p><p>There is a diet that has been shown to reverse diabetic eye disease: Dr.</p><p>Kempner’s rice and fruit diet. More than a half century ago, Walter</p><p>Kempner at Duke University showed that his plant-based diet, ultralow in</p><p>sodium, fat, cholesterol, and animal protein, could not only reverse</p><p>advanced heart and kidney failure584 but diabetic retinopathy as well, with</p><p>some</p><p>patients going from not even being able to read headlines to having</p><p>normal vision.585</p><p>How do we treat severe diabetic retinopathy these days? With</p><p>intravitreal drugs (meaning injections straight into your eyeball). If those</p><p>don’t work, there’s always panretinal laser photocoagulation, in which laser</p><p>burns are etched over nearly the entire back of your eye586 in the hope that</p><p>the little pieces left behind may get more of the blood flow.587 When I see</p><p>this, along with Kempner’s work, I can’t help but feel like history has been</p><p>reversed. It would be one thing if, a half century ago, the best we had was a</p><p>barbaric burn-out-your-eye-socket surgery but, thankfully, we’ve since</p><p>learned that we can reverse the vision loss through dietary means alone. But</p><p>instead of learning, medicine seems to have forgotten.</p><p>Kempner also proved massive obesity could be corrected “without</p><p>drastic intervention,” showing people could lose hundreds of pounds</p><p>through lifestyle changes alone, without resorting to hospitalization, drugs,</p><p>or surgery.588 His diet was itself pretty drastic (certainly not to be</p><p>undertaken without medical supervision),589 but at least it didn’t entail</p><p>getting one’s internal organs cut open and stapled. “Even if surgery proves</p><p>sustainably effective,” wrote the founding director of the Yale-Griffin</p><p>Prevention Research Center, “the need to rely on the rearrangement of</p><p>natural gastrointestinal anatomy as an alternative to better use of feet and</p><p>forks [exercise and diet] seems a societal travesty.”590</p><p>Through Thick and Thin</p><p>How sustainable is weight loss with bariatric surgery? Over the first year or</p><p>two after the procedure, most gastric bypass patients do end up regaining</p><p>some of the weight they had lost,591 but five years later, three-quarters</p><p>maintain at least a 20 percent weight loss.592 The typical trajectory for</p><p>someone who starts out obese at 285 pounds, for example, would be to drop</p><p>to an overweight 178 pounds two years after bariatric surgery but then</p><p>regain back up to an obese 207 pounds.593 This has been chalked up to</p><p>“grazing” behavior, where compulsive eaters may shift from bingeing,</p><p>which becomes more difficult post-surgery, to constantly eating smaller</p><p>amounts throughout the day.594 Eight years out, about half of gastric bypass</p><p>patients continue to describe episodes of disordered eating.595 As one</p><p>pediatric obesity specialist described, “I have seen many patients who put</p><p>chocolate bars into a blender with some cream, just to pass technically</p><p>installed obstacles” such as a gastric band.596</p><p>Bariatric surgery advertisements are filled with happily-ever-after fairy-</p><p>tale narratives of cherry-picked outcomes, offering, as one ad analysis put</p><p>it, “the full Cinderella-romance happy ending.”597 This may contribute to</p><p>the finding that patients often overestimate the amount of weight they’re</p><p>going to lose and underestimate the difficulty of the recovery process.598</p><p>Surgery forces profound changes in eating habits, requiring slow, small,</p><p>thoroughly chewed bites. The stomach goes from the volume of two</p><p>softballs down to about the size of half a tennis ball in stomach stapling and</p><p>about half a Ping-Pong ball in the case of gastric bypass or banding.599</p><p>As you can imagine, weight regain after surgery can have devastating</p><p>psychological effects, as patients may feel they failed their last resort.600</p><p>This could help explain why bariatric surgery patients are at a higher risk of</p><p>depression601 and suicide.602 Severe obesity alone may increase risk of</p><p>suicidal depression,603 but even at the same weight, those going through</p><p>surgery appear to be at higher risk.604 At the same BMI, age, and gender,</p><p>bariatric surgery recipients have about four times the odds of suicide.605</p><p>Most convincingly, before-and-after “mirror-image analysis” shows the risk</p><p>of serious self-harm increases post-surgery in the same individuals.606</p><p>Nearly one in fifty bariatric surgery patients ends up being hospitalized</p><p>for self-harm or attempted suicide.607 Furthermore, this only includes</p><p>confirmed self-harm episodes, excluding masked attempts608 such as</p><p>overdoses of “undetermined intention.”609 Bariatric surgery patients also</p><p>have an elevated risk of “accidental death,”610 though some of this may be</p><p>due to changes in alcohol metabolism. When gastric bypass patients have</p><p>two shots of vodka, for example, because of their altered anatomy, their</p><p>blood alcohol levels shoot up past the legal driving limit within minutes.611</p><p>It’s unclear, however, whether this plays a role in the 25 percent increase in</p><p>prevalence of alcohol problems noted during the second postoperative</p><p>year.612</p><p>Even those who successfully lose the excess weight and keep it off</p><p>appear to have a hard time coping. Ten years out, though health-related</p><p>quality of life improves, general mental health tends to significantly</p><p>deteriorate compared to presurgery levels—even among the biggest</p><p>losers.613 Ironically, there’s a common notion that bariatric surgery is for</p><p>“cheaters”614 who take the “easy way” out by choosing the “low-effort”</p><p>method of weight loss.615 Shedding the pounds may not shed the stigma of</p><p>even prior obesity. Studies suggest that, in the eyes of others, knowing</p><p>someone was fat in the past leads them to always be treated more like a fat</p><p>person. And there’s a strong anti-surgery bias on top of that, such that those</p><p>who choose the scalpel to lose weight are rated most negatively (for</p><p>example, thought of as least physically attractive).616 One can imagine how</p><p>remaining a target of prejudice even after joining the “in-group” could</p><p>potentially undercut psychological well-being.</p><p>Weighing the Options</p><p>In the Middle Ages, starving peasants dreamed of gastronomic utopias</p><p>where food rained down from the sky. The English called it the Kingdom of</p><p>Cockaigne. Little could medieval fabulists predict that many of their</p><p>descendants would not only take permanent residence there but also cut out</p><p>parts of their stomachs and intestines to combat the abundance.617</p><p>A body gaining weight when excess calories are available for</p><p>consumption is behaving as it should.618 Efforts to curtail such weight gain</p><p>with drugs or surgery are not efforts to correct an anomaly in human</p><p>physiology but rather to deconstruct and reconstruct its normal operations at</p><p>the core. Critics have pointed out this irony of surgically altering healthy</p><p>organs to make them dysfunctional (“malabsorptive”) on purpose,619</p><p>especially when it comes to operating on children. Bariatric surgery for kids</p><p>and teens is becoming widespread620 and is being performed in children as</p><p>young as five years old.621 Surgeons defend the practice by arguing that</p><p>growing up fat can leave emotional scars and “lifelong social</p><p>retardation.”622</p><p>Promoters of preventive medicine argue that bariatric surgery is the</p><p>proverbial “ambulance at the bottom of the cliff.”623 In response, a</p><p>proponent of pediatric bariatric surgery said, “It is often pointed out that we</p><p>should focus on prevention. Of course, I agree. However, if someone is</p><p>drowning, I don’t tell them, ‘You should learn how to swim’; no, I rescue</p><p>them.”624</p><p>A strong case can be made that the benefits of bariatric surgery far</p><p>outweigh the risks if the alternative is remaining morbidly obese, which is</p><p>estimated to shave off up to thirteen years of one’s life.625 Although there</p><p>are no data from randomized trials yet to back it up, compared to obese</p><p>individuals who hadn’t been operated on, those getting bariatric surgery</p><p>would be expected to live significantly longer on average.626 It’s no wonder</p><p>surgeons consistently frame the elective surgery as a life-or-death</p><p>necessity,627 but this is a false dichotomy. The benefits only outweigh the</p><p>risks if there are no other alternatives.</p><p>Like Lead Balloons</p><p>With much fanfare, the 1980s brought us intragastric balloons that could be</p><p>implanted into the stomach and inflated with air or water to fill up much of</p><p>the space.628 Sadly, surgical devices are often brought to market before there</p><p>is adequate evidence of safety and effectiveness,629</p><p>possible tweak and technique we could find to build</p><p>the optimal weight-control solution from the ground up.</p><p>I went into this project with the goal of creating a distillation of all the</p><p>best science, but to my delight, I discovered all sorts of exciting new tools</p><p>and tricks along the way. We did indeed uncover a treasure trove of buried</p><p>data, like simple spices proven in randomized, double-blind, placebo-</p><p>controlled studies to accelerate weight loss for pennies a day. With so little</p><p>profit potential, it’s no wonder those studies never saw the light of day.</p><p>And we were even able to traverse beyond the existing evidence base to</p><p>propose a novel method to eliminate body fat. The proposed technique</p><p>appears to have a strong theoretical basis but has never been put to the test</p><p>because apparently no one has ever thought of it before. It can’t be</p><p>monetized either, but the only profiting I care about is your health. That’s</p><p>why I donate to charity 100 percent of the proceeds I get from my DVDs,</p><p>speaking engagements, and books, including the one you’re holding right</p><p>now. I just want to do for everyone’s family what Pritikin did for mine.</p><p>Introduction</p><p>SOMETIMES BIGGER IS BETTER</p><p>My literary agent told me that no one wants a fat diet book. They want it to</p><p>be as slim as they envision their future selves. Sorry to disappoint, but I</p><p>couldn’t help it. I wanted to document every evidence-based tip, trick,</p><p>tweak, and hack to give people every possible advantage—whether you’re</p><p>obese, overweight, or just wanting to maintain your ideal weight.</p><p>In How Not to Diet, I cover everything from cultivating a healthy</p><p>microbiome in your gut to manipulating your metabolism through</p><p>chronobiology, matching meal timing to your circadian rhythms. Every</p><p>section could have been a book in its own right. We certainly attempted</p><p>book-length research on each subject and then tried to distill down the most</p><p>compelling, actionable takeaways from each of the most promising</p><p>strategies. To that end, this is really more like forty books packed into one.</p><p>For those of you now wielding a physical copy of the book and thinking,</p><p>This is the compact version?, take comfort in the fact that you can use it to</p><p>curl for a little extra resistance exercise.</p><p>It was important to me to include all the details so you can make as</p><p>informed a decision about your health as possible, but you can always skip</p><p>down to the summaries at the end of each section for my take-home</p><p>suggestions. I wanted to be sure to clearly articulate how I arrived at each</p><p>recommendation, because I don’t want to be anyone’s diet guru. I don’t</p><p>want you to take anything on faith but rather on evidence.</p><p>In the References section, I’ve included a website address and a QR code</p><p>for the full list of the nearly five thousand citations referenced throughout</p><p>this book. The advantage of presenting them online for you (beyond</p><p>trimming five hundred pages and saving a few trees) is that it allowed me to</p><p>hyperlink each and every citation to take you directly to the source, so you</p><p>can download the PDFs and access the original research yourself. Here in</p><p>the ebook you get the best of both worlds, with the full list of citations plus</p><p>the code to access the primary sources.</p><p>Some of my conclusions are scientific slam dunks, but others are more</p><p>uncertain, and I try to make the distinctions clear. That way, you can make</p><p>up your own mind when trying to decide whether to incorporate any</p><p>particular piece of my advice into your life. If you find yourself</p><p>unconvinced by the data presented to support a particular recommendation,</p><p>don’t do it. The benefit of laying it all out is that you can decide for</p><p>yourself. As famed scientist Carl Sagan (who also happened to be my next-</p><p>door neighbor at Cornell!) put it: “Science by itself cannot advocate courses</p><p>of human action, but it can certainly illuminate the possible consequences</p><p>of alternative courses of action.”9</p><p>WHAT ARE YOUR DIGITS?</p><p>Before we dive in, what does it really mean to be overweight? Obese? In</p><p>simple terms, being overweight means you have too much body fat,</p><p>whereas being obese means you have way too much body fat. In technical</p><p>terms, obesity is operationally defined as a body mass index (BMI) of 30 or</p><p>more, while being overweight means you have a BMI of 25 to 29.9. A BMI</p><p>between 18.5 and 24.9 is considered “ideal weight.”</p><p>Calculating your BMI is relatively easy: You can visit one of the scores</p><p>of online BMI calculators, or you can grab a calculator and calculate it on</p><p>your own. To do so, multiply your weight in pounds by 703. Then divide</p><p>that twice by your height in inches. For example, if you weigh 200 pounds</p><p>and are 71 inches tall (five foot eleven), that would be (200 × 703) ÷ 71 ÷</p><p>71 = 27.9, a BMI indicating that you would be, unfortunately, significantly</p><p>overweight.</p><p>In the medical profession, we used to call a BMI under 25 “normal</p><p>weight.” Sadly, that’s no longer normal. Being overweight became the norm</p><p>by the late 1980s in the United States10 and appears to have steadily</p><p>worsened ever since.11</p><p>ISN’T A CALORIE A CALORIE?</p><p>Now that we see where the lines are drawn in the weight spectrum from</p><p>optimal to obese, let’s review some basic assumptions. The notion that a</p><p>calorie from one source is just as fattening as a calorie from any other</p><p>source is a trope broadcast by the food industry as a way to absolve itself of</p><p>culpability. Coca-Cola even put out an ad emphasizing this “one simple</p><p>commonsense fact.”12 As the chair of Harvard’s nutrition department put it,</p><p>this “central argument” from industry is that the “overconsumption of</p><p>calories from carrots would be no different from overconsumption of</p><p>calories from soda.”13 If a calorie is just a calorie, why does it matter what</p><p>kinds of foods we eat?</p><p>Let’s take the example of carrots versus Coca-Cola. While it’s true that</p><p>in a tightly controlled laboratory setting, 240 calories of carrots—ten carrots</p><p>—would have the same effect on calorie balance as the 240 calories in a</p><p>bottle of Coke,14 this comparison falls flat on its face out in the real world.</p><p>You could chug down those liquid calories in less than a minute, but eating</p><p>240 calories of carrots could take you more than two and a half hours of</p><p>constant chewing. (It’s been timed.15) Not only would your jaw get sore, but</p><p>240 calories of carrots is about five cups—you might not even be able to fit</p><p>them all in your stomach. Like all whole plant foods, carrots have fiber,</p><p>which adds bulk without adding net calories. What’s more, you wouldn’t</p><p>even absorb all the carrot calories. As anyone who’s eaten corn can tell you,</p><p>some bits of vegetable matter can pass right through you, flushing out any</p><p>calories they contain. A calorie may still be a calorie circling your toilet</p><p>bowl, but it’s not going to end up on your hips.</p><p>A more relatable comparison might be something like Cheerios versus</p><p>Froot Loops. As Kellogg’s is practically giddy to point out, its Froot Loops</p><p>cereal has about the same number of calories as its rival’s health-hallowed</p><p>Cheerios. So why does Toucan Sam get singled out? (I was deposed as an</p><p>expert witness in a case against sugary cereal manufacturers, so I heard</p><p>these arguments firsthand.) Yes, the two cereals may have similar calories,</p><p>but that doesn’t take into account all the appetite-stimulating effects of</p><p>concentrated sugar.16 In an experiment in which children were alternately</p><p>offered high-versus lower-sugar cereals, had they eaten more Cheerios than</p><p>Froot Loops, they could have gotten more calories, but the opposite</p><p>happened. On average, the kids poured and ate 77 percent more of the</p><p>sugary cereal. So even with comparable calorie counts, sugary cereals may</p><p>end up nearly doubling caloric intake.17 In a lab, a calorie is a calorie, but in</p><p>life, far from it.</p><p>Even if you eat and absorb the same number of calories, a calorie may</p><p>still not be a calorie. As you’ll learn, the same number of calories eaten at a</p><p>different time of the day, in a different meal distribution, or after different</p><p>amounts of sleep can translate into different amounts</p><p>and the balloons were no</p><p>exception.</p><p>The “Gastric Bubble” had its bubble burst when a study at the Mayo</p><p>Clinic found that eight out of ten balloons spontaneously deflated (which is</p><p>potentially dangerous, as they could pass into the intestines and cause an</p><p>obstruction630), but not before causing gastric erosions—that is, damage to</p><p>the stomach lining—in half the patients.631 The kicker is that, in terms of</p><p>inducing weight loss, the device didn’t even work.632 It was eventually</p><p>pulled from the market, but now balloons are back.</p><p>After a thirty-three-year hiatus, the FDA started approving a new slew of</p><p>intragastric balloons in 2015,633 resulting in more than five thousand</p><p>placements.634 By then, the Sunshine Act had been passed in order to shine</p><p>a disinfecting light on industry enticements by forcing drug companies and</p><p>the surgical and medical device industry to disclose any payments they</p><p>were making to physicians.635 Most people now know about the overly cozy</p><p>financial relationships doctors can have with Big Pharma, but fewer realize</p><p>that surgeons can also get payments from the companies manufacturing the</p><p>devices they use.636 The hundred top recipients of industry payments</p><p>received an unbelievable $12 million from device companies in a single</p><p>year. Yet when these doctors published papers, only a minority disclosed the</p><p>blatant conflict of interest.637</p><p>The benefit of balloons over most types of bariatric surgery is that</p><p>they’re reversible, but that doesn’t mean they’re benign. The FDA has</p><p>released a series of advisories about their risks, which includes cases of</p><p>patient fatalities due to a stomach rupture.638 How could someone suffer a</p><p>gastric perforation from a smooth, rounded object? By causing the patient</p><p>to puke so much they rip open their stomach and die.639 Nausea and</p><p>vomiting are unsurprising and very common side effects, affecting the</p><p>majority of those who have balloons placed.640 Persistent vomiting likely</p><p>also explains cases of life-threatening nutrient deficiencies after balloon</p><p>implantation.641</p><p>Some complications, such as bowel obstruction, are due to the balloon</p><p>deflating,642 but others, oddly enough, are due to the balloons suddenly</p><p>overinflating,643 causing pain, vomiting, and abdominal distention.644 This</p><p>was first noticed in breast implants, as documented in reports such as “The</p><p>Phenomenon of the Spontaneously Autoinflating Breast Implant.”645 Out of</p><p>nowhere, the implants just started growing, increasing breast volume by an</p><p>average of more than 50 percent.646 “It remains,” one review noted, “an</p><p>underreported and poorly understood phenomenon.”647 (Interestingly, breast</p><p>implants were actually used as some of the first failed experimental</p><p>intragastric balloons.648)</p><p>As with any medical decision, though, it’s all about risks versus benefits.</p><p>Industry-funded trials display notable weight loss, but it’s hard to tease out</p><p>the effect of the balloon alone from the accompanying supervised diet and</p><p>lifestyle changes prescribed along with the devices in the studies.649 In drug</p><p>trials, you can randomize subjects to sugar pills, but how do you eliminate</p><p>the placebo effect of undergoing a procedure? You perform sham surgery.</p><p>In 2002, a courageous study was published in The New England Journal</p><p>of Medicine. Knee arthroscopy, the most common orthopedic surgery, was</p><p>put to the test. Billions of dollars are spent sticking scopes into knee joints</p><p>and cutting away damaged tissue in osteoarthritis and knee injuries, but</p><p>does the surgery actually work? Knee pain sufferers were randomized to get</p><p>either the real surgery or a sham surgery in which surgeons sliced into</p><p>people’s knees and pretended to perform the procedure, complete with</p><p>splashing saline, but never actually did anything within the joint.</p><p>The trial caused an uproar. How could anyone randomize people to get</p><p>cut open for fake surgery? Professional medical associations questioned the</p><p>ethics of the surgeons and the sanity of the patients who agreed to be part of</p><p>the trial.650 But guess what happened? Yes, the surgical patients got better,</p><p>but so did the placebo patients. The surgeries had no actual effect.651,652</p><p>Currently, heart stents653 and rotator cuff shoulder surgery are facing the</p><p>same crisis of confidence.654</p><p>When intragastric balloons were put to the test, sham controlled trials</p><p>show both older655 and newer656 devices sometimes fail to offer any weight-</p><p>loss benefit. Even when they do work,657 the weight loss may be temporary</p><p>because balloons are only allowed to stay in for six months, at which point</p><p>the deflation risk gets too great. Why can’t we keep putting in new ones?</p><p>That’s been tried, and it failed to improve long-term weight outcomes.658 A</p><p>sham controlled trial showed that any effects of the balloon on appetite and</p><p>satiety may vanish with time,659 perhaps as our bodies get used to the new</p><p>normal.</p><p>What sham-surgery trials have shown us is that some of our most</p><p>popular surgeries are themselves shams. Doctors like to pride themselves on</p><p>being men and women of science. We rightly rail against the anti-</p><p>vaccination movement, for example. Many of us in medicine have been</p><p>troubled by the political trend of people choosing their own “facts.” When I</p><p>read that some of these still-popular surgeries are not only useless660 but</p><p>may actually make things worse—for example, increasing the risk of</p><p>progression to a total knee replacement661—I can’t help but think we</p><p>doctors are not immune to our own versions of “fake news” and “alternative</p><p>facts.”662</p><p>Diet Drugs</p><p>One Pill Makes You Smaller</p><p>We worship medical magic bullets in this country. Yet, despite the full menu</p><p>of FDA-approved medications for weight loss these days, they’ve only been</p><p>prescribed for about one in fifty obese patients.663 What gives? One of the</p><p>reasons anti-obesity drugs are so highly stigmatized664 is that, historically,</p><p>they’ve been anything but magical; the bullets have been blanks, or</p><p>worse.665</p><p>To date, most weight-loss drugs, despite their initial approval, have been</p><p>pulled from the market for unforeseen side effects that turned them into a</p><p>public threat.666 As I explore in the Fat Burners section, it all started with</p><p>DNP, a pesticide with a promise to safely melt away fat667—but instead</p><p>melted away people’s eyesight.668 (The DNP disaster, in fact, helped lead to</p><p>the passage of the Federal Food, Drug, and Cosmetic Act in 1938.669)</p><p>Thanks to online accessibility, DNP has made a comeback with predictably</p><p>lethal results.670</p><p>Then came the amphetamines. Currently, more than half a million</p><p>Americans are addicted to amphetamines like crystal meth,671 but the</p><p>original amphetamine epidemic was generated by doctors and drug</p><p>companies.672 By the 1960s, pharmaceutical companies were churning out</p><p>about eighty thousand kilos a year, which is nearly enough for a weekly</p><p>dose for every man, woman, and child in the United States. Literally</p><p>billions of doses were taken each year, and weight-loss clinics were raking</p><p>in huge profits. A dispensing diet doctor could buy one hundred thousand</p><p>amphetamine tablets for less than $100 and turn around and sell them to</p><p>patients for $12,000.673</p><p>At a 1970 Senate hearing, Senator Thomas Dodd, father of Dodd-Frank</p><p>senator Chris Dodd, suggested America’s speed freak problem was no</p><p>“accidental development.” He said the pharmaceutical industry’s</p><p>“multihundred million dollar advertising budgets, frequently the most costly</p><p>ingredient in the price of a pill, have, pill by pill, led, coaxed and seduced</p><p>post–World War II generations into the ‘freakedout’ drug culture.”674 I’ll</p><p>leave drawing the Big Pharma parallels to the current opioid crisis as an</p><p>exercise for the reader.</p><p>Aminorex was a widely prescribed appetite suppressant before it was</p><p>pulled for causing lung damage.675 Eighteen million Americans were on</p><p>fen-phen before it was pulled676 for causing severe damage to heart</p><p>valves.677 Meridia was pulled for heart attacks and strokes,678 Acomplia for</p><p>psychiatric side effects including suicide,679 and the list goes on.680</p><p>The fen-phen debacle resulted</p><p>in some of the largest litigation payouts in</p><p>the industry’s history, but it’s all baked into the formula.681 A new weight-</p><p>loss drug may injure and kill so many that “expected litigation cost” could</p><p>exceed $80 million, but Big Pharma consultants estimated in the journal</p><p>PharmacoEconomics that, if successful, the drug could bring in excess of</p><p>$100 million.682 You do the math.</p><p>Think Outside the Black Box</p><p>Current options for weight-loss medications include Qsymia, a combination</p><p>of phentermine, the phen in fen-phen, and topiramate, a drug that can cause</p><p>seizures if you abruptly stop taking it.683 Qsymia was explicitly rejected</p><p>multiple times for safety reasons in Europe but remains for sale in the</p><p>United States. Belviq (lorcacerin) is in a similar boat, allowed here but not</p><p>in Europe out of concerns about it possibly causing cancers, psychiatric</p><p>disorders, and heart valve problems.684 It’s sold in the United States for</p><p>about $200 a month, a bargain compared to the latest addition: Saxenda</p><p>(liraglutide).</p><p>A drug requiring daily injections, Saxenda is listed at $1,281.96 for a</p><p>thirty-day supply.685 It carries a black box warning—FDA’s strictest caution</p><p>about potentially life-threatening hazards—for thyroid cancer risk.686 Paid</p><p>consultants and employees of the company that makes it argue the greater</p><p>number of breast tumors found among drug recipients may be due to</p><p>“enhanced ascertainment,” meaning easier breast cancer detection due to</p><p>the drug’s effectiveness.687 Contrave (bupropion/naltrexone) is another</p><p>option if you choose to ignore its own black box warning about a potential</p><p>increase in suicidal thoughts.688</p><p>Alli (orlistat) is the final choice. That’s the drug that blocks fat</p><p>absorption and causes side effects such as “flatus with discharge.”689 The</p><p>drug evidently “forces the patient to use diapers and to know the location of</p><p>all the bathrooms in the neighborhood in an attempt to limit the</p><p>consequences of urgent leakage of oily fecal matter.”690 A Freedom of</p><p>Information Act exposé found that although company-sponsored studies</p><p>claimed “all adverse events were recorded,”691 one trial apparently</p><p>conveniently failed to mention 1,318 of them.692</p><p>What’s a little bowel leakage compared to the ravages of obesity,</p><p>though? 693 As always, risks versus benefits, right? But in an analysis of</p><p>more than one hundred clinical trials of anti-obesity medications lasting up</p><p>to forty-seven weeks, drug-induced weight loss never exceeded nine</p><p>pounds.694 Since you’re not treating the underlying cause—a fattening diet</p><p>—the weight tends to come right back when people stop taking these</p><p>drugs,695 so you’d have to take them every day for the rest of your life. How</p><p>well are people able to stay on them? Using pharmacy data from a million</p><p>people, most Alli users stopped after the first purchase, and most Meridia</p><p>users didn’t even make it three months. Taking weight-loss meds is so</p><p>disagreeable that 98 percent of people stopped taking them within the first</p><p>year.696</p><p>Studies show many doctors tend to overestimate the amount of weight</p><p>loss caused by these drugs.697 One reason may be that some clinical practice</p><p>guidelines, like those of the Endocrine Society, go out of their way to</p><p>advocate pharmacotherapy for obesity.698 Are they seriously recommending</p><p>drugging 40 percent of Americans—more than one hundred million</p><p>people? 699 At this point, you will not be surprised to learn that the principal</p><p>author of the guidelines had a “significant financial interest or leadership</p><p>position” in six separate pharmaceutical companies that all, coincidentally,</p><p>work on obesity drugs.700 In contrast, independent expert panels, like the</p><p>Canadian Task Force on Preventive Health Care, explicitly recommend</p><p>against weight-loss drugs given their poor track records of safety and</p><p>efficacy.701</p><p>Weight-Loss Supplements</p><p>Bad Manufacturing Practices</p><p>According to a national survey, a third of adults who’ve made serious</p><p>efforts at weight loss have tried using dietary supplements,702 for which</p><p>Americans spend literally billions of dollars every year.703 Most people</p><p>surveyed mistakenly thought that over-the-counter appetite suppressants,</p><p>herbal products, and weight-loss supplements had to be approved for safety</p><p>by a government agency like the FDA before being sold to the public—or at</p><p>least include some kind of warning on the label about potential side effects.</p><p>Nearly half even thought they had to demonstrate some sort of</p><p>effectiveness.704 None of that is true.</p><p>The FDA estimates that dietary supplements in general cause fifty</p><p>thousand adverse events annually,705 most commonly liver and kidney</p><p>damage.706 Meanwhile, prescription drugs don’t just adversely affect but</p><p>actually kill more than one hundred thousand Americans every year.707 But</p><p>at least with prescription meds, you notionally have the opportunity to parse</p><p>out the risks versus the benefits, thanks to testing and monitoring</p><p>requirements typically involving thousands of individuals.708 When the</p><p>manufacturer of the ephedrine-containing dietary supplement Metabolife</p><p>356 had it tested in a study that ended up with just twenty-four people, only</p><p>minor side effects were found (like dry mouth, headache, and insomnia).709</p><p>However, once unleashed on the populace, nearly fifteen thousand adverse</p><p>effects were reported before it was pulled from the market, including heart</p><p>attacks, strokes, seizures, and deaths.710</p><p>Given the lack of government oversight, there’s no guarantee that what’s</p><p>on the label is even inside the bottle. FDA inspectors have found that 70</p><p>percent of supplement manufacturers violated so-called Good</p><p>Manufacturing Practices, which are considered the minimum quality</p><p>standards,711 such as basic sanitation and ingredient identification. Not 7</p><p>percent, but 70 percent.</p><p>DNA testing of herbal supplements across North America found that</p><p>most could not be authenticated. In 68 percent of the supplements tested,</p><p>the main labeled ingredient was missing completely and substituted with</p><p>something else. For example, a “St. John’s Wort” supplement contained</p><p>nothing but senna,712 a laxative that can cause anal blistering.713 Only two</p><p>out of twelve supplement companies had products that were accurately</p><p>labeled.714</p><p>The problem isn’t limited just to fly-by-night phonies in some dark</p><p>corner of the internet. The New York State Attorney General commissioned</p><p>DNA testing of seventy-eight bottles of commercial herbal supplements</p><p>sold by Walgreens, Walmart, Target, and GNC. Four out of five bottles</p><p>didn’t contain any of the herbs listed on their labels. Instead, capsules were</p><p>often stuffed with little more than cheap fillers like powdered rice “and</p><p>houseplants.”715</p><p>Getting More Than You Paid For</p><p>Weight-loss supplements are also infamous for being adulterated with</p><p>drugs.716 Of 160 “100% natural” weight-loss supplements sampled, more</p><p>than half were tainted with drugs, ranging from antidepressants to erectile</p><p>dysfunction meds.717 Diuretic drugs are frequent contaminants, which</p><p>makes sense.718 In the Intermittent Fasting section, I talk about rapid water</p><p>loss as the billion-dollar gimmick that has sold low-carb diets for more than</p><p>a century.</p><p>Researchers in Denver tested every weight-loss supplement they could</p><p>find within a ten-mile radius and alarmingly found a third were adulterated</p><p>with banned ingredients, and 90 percent contained “discouraged-use”</p><p>components.719 The most common illegal adulterant of weight-loss</p><p>supplements is sibutramine, the Meridia drug that was yanked off the</p><p>market back in 2010 for heart attack and stroke risk,720 and is now blamed</p><p>for cases of slimming supplement–induced psychosis.721 An analysis of</p><p>weight-loss supplements bought off the internet and advertised with claims</p><p>such as “purely natural,” “harmless,” or “traditional herbal” found that a</p><p>third contained a high dose of sibutramine and the rest contained caffeine.</p><p>Wouldn’t we be able to tell if caffeine were added to a supplement? Perhaps</p><p>not if the supplement also contained temazepam, a controlled-substance</p><p>benzodiazepine downer sedative</p><p>found in half of the caffeine-tainted</p><p>supplements.722</p><p>Doesn’t the FDA demand recalls of adulterated supplements? Yes, but</p><p>the pills just pop up again on store shelves. Twenty-seven supplements</p><p>purchased at least six months after recalls were retested, and two-thirds still</p><p>contained banned substances. At the follow-up testing, seventeen</p><p>supplements out of twenty-seven had the same pharmaceutical adulterant</p><p>found originally, and six contained one or more additional banned</p><p>ingredients.723 And unfortunately, the manufacturers aren’t sufficiently</p><p>penalized for noncompliance. As a founding fellow of the Institute for</p><p>Science in Medicine put it, “Fines for violations are small compared to the</p><p>profits.”724</p><p>Slim Pickings</p><p>One of the ways supplement makers can skirt the law is by labeling them</p><p>“not intended for human consumption,” for example, labeling the fatal fat-</p><p>burner DNP as an industrial or research chemical.725 That’s how designer</p><p>street drugs can be sold openly at gas stations and convenience stores as</p><p>“bath salts.”726 Another way is to claim that synthetic stimulants added to</p><p>slimming supplements are actually natural food constituents, like listing the</p><p>designer drug dimethylamylamine as “geranium oil extract.” The FDA</p><p>banned dimethylamylamine in 2012 after it was determined DMAA was</p><p>“not found in geraniums.” (Who eats geraniums anyway?727) Despite being</p><p>tentatively tied to cases of sudden death728 and hemorrhagic stroke,729</p><p>DMAA has continued to be found in weight-loss supplements with</p><p>innocuous names like Simply Skinny Pollen made by Bee Fit with Trish.730</p><p>There is little doubt that certain banned supplements like ephedra could</p><p>help people lose weight.731 “There’s only one problem,” wrote a founding</p><p>member of the American Board of Integrative Medicine. “This supplement</p><p>may kill you.”732</p><p>Are there any safe and effective dietary supplements for weight loss?</p><p>When nine popular slimming supplements were put to the test in a</p><p>randomized placebo-controlled trial, not a single one could beat out placebo</p><p>sugar pills.733 A systematic review of diet pills came to a similar conclusion:</p><p>None appears to generate appreciable impacts on body weight without</p><p>undue risks.734 One such systematic review of “nutraceutical” supplements</p><p>out of the Weight Management Center at Johns Hopkins University ended</p><p>with this:</p><p>In closing, it is fitting to highlight that perhaps the most general and</p><p>safest alternative/herbal approach to weight control is to substitute</p><p>low–energy density foods for high–energy density and processed</p><p>foods, thereby reducing total energy intake. By taking advantage of</p><p>the low–energy density and health-promoting effects of plant-based</p><p>foods, one may be able to achieve weight loss, or at least assist</p><p>weight maintenance without cutting down on the volume of food</p><p>consumed or compromising its nutrient value.735</p><p>Licensed to Swill</p><p>Even if harmless, there’s a way weight-loss supplements could actually make you gain weight,</p><p>thanks to a fascinating glitch of human psychology called self-licensing.736 This is when we</p><p>unwittingly justify doing something that pulls us away from our goals, right after we’ve done</p><p>something that moves us toward them. We reward ourselves with an indulgence that sets us</p><p>back.</p><p>When smokers were told they were given “vitamin C” supplements, they subsequently</p><p>smoked more cigarettes than if they had been given what were identified as “placebo” pills—</p><p>even though both groups had been given identical sugar pills. The “vitamin C” group smoked</p><p>nearly twice as much, perhaps thinking at some subconscious level that since they had just</p><p>done something good for their health by taking a “supplement,” they could afford to “live a</p><p>little,” when, in effect, it may have indeed occasioned them to live a little … less.737</p><p>You can see how self-licensing can translate into other lifestyle arenas. Other studies have</p><p>shown that those given placebo pills they believed to be dietary supplements not only</p><p>expressed less desire to subsequently engage in exercise but followed through by walking</p><p>about a third less. Compared to those who were told the pills were placebos, misled</p><p>participants were also more likely to choose a buffet over a “healthful, organic meal.”738</p><p>Would they eat more too? A seminal study entitled “The Liberating Effect of Weight Loss</p><p>Supplements on Dietary Control” put it to the test.</p><p>Participants were randomized to take a known placebo or a purported weight-loss</p><p>supplement that was actually just the same placebo, and they were later covertly observed at a</p><p>buffet. Not only did the “supplement” subjects eat more foods, they chose less-healthy</p><p>items.739 They also ate about 30 percent more candy in a bogus “taste test” and ordered more</p><p>sugary drinks.740 “Hence,” the investigators concluded, “people who rely on dietary</p><p>supplements for health protection may pay a hidden price: the curse of licensed self-</p><p>indulgence.”741</p><p>Policy Approaches</p><p>System Failure</p><p>The public health community appears to have all but given up on ending the</p><p>obesity epidemic. The latest World Health Organization goals include a</p><p>2025 obesity target of just trying to shoot for a zero increase in further</p><p>prevalence.742 Even such a modest-sounding low bar may represent one of</p><p>the greatest challenges facing global health. Though there have been</p><p>isolated pockets of patchy progress, no country has yet reversed the</p><p>epidemic.</p><p>The promotion of the overconsumption of high-calorie, low-nutrient</p><p>foods and beverages has been identified as the major driver of the obesity</p><p>pandemic.743 Now that we have rid much of the world of pestilence and</p><p>famine, some public health proponents have gone as far as to suggest that</p><p>the “new vectors of disease” are taking the form of “trans-national food</p><p>corporations that market salt, fat, sugar, and calories in unprecedented</p><p>quantities.”744 Blame has been laid at the feet of lobbying efforts of the food</p><p>industry,745 which is considered the world’s biggest industry.746 The</p><p>processed food makers alone may bring in trillions.747 “Put simply,”</p><p>concluded a senior director at the George Institute for Global Health, “the</p><p>enormous commercial success enjoyed by the food industry is now causing</p><p>what promises to be one of the greatest public health disasters of our</p><p>time.”748</p><p>But remember—corporations just do what they’re set up to do. Their</p><p>goal is not to make people fat but to make people money.749 The food</p><p>industry manipulates ingredients like salt, sugar, and fat and throws in</p><p>caffeine and flavor-enhancing chemicals for reasons no more nefarious than</p><p>maximizing profits. Markets often incentivize companies to cater to, and</p><p>take advantage of, human weaknesses.750 The food and beverage CEOs</p><p>simply have a fiduciary responsibility to maximize quarterly profits for</p><p>their shareholders.</p><p>But why not sell apples instead of Apple Jacks or oranges instead of</p><p>Orange Crush? To quote from Slick Willie Sutton’s apocryphal answer to</p><p>why he robbed banks: “That’s where the money is.” The reason some of the</p><p>unhealthiest foods are marketed is one of simple economics: Real food goes</p><p>bad.751 Fruits and vegetables are perishable. What shareholders want is a</p><p>snack cake that lasts for weeks on the shelf.</p><p>On top of that, real food doesn’t have brand names. Why would a</p><p>broccoli grower put an ad on TV when you’d just as likely buy their</p><p>competitor’s broccoli? The system is simply not set up to reward the sale of</p><p>health-promoting food.</p><p>And finally, real food costs money to grow. Shareholders don’t want dirt</p><p>—they want dirt-cheap commodities such as corn syrup, preferably</p><p>discounted by taxpayer subsidies, that they can then mix with carbonated</p><p>water and sell for a few bucks a bottle. Burgers on the Dollar Menu are</p><p>there thanks in part to hundreds of billions of dollars of federal subsidies for</p><p>cheap animal feed.752 Those who resist calls for “heavy-handed”</p><p>government regulation may not realize those heavy hands are already</p><p>pressing down the scale on the side of Big Business.</p><p>Using the Anti-Tobacco Playbook</p><p>What we learned from</p><p>the tobacco experience, wrote two preeminent public</p><p>health scholars, is how powerfully profits can motivate “even at the cost of</p><p>millions of lives and unspeakable suffering.” Here they quote a U.S. district</p><p>judge ruling on a tobacco case:</p><p>All too often in the choice between the physical health of consumers</p><p>and the financial well-being of business, concealment is chosen over</p><p>disclosure, sales over safety, and money over morality. Who are these</p><p>persons who knowingly and secretly decide to put the buying public at</p><p>risk solely for the purpose of making profits, and who believe that</p><p>illness and death of consumers is an apparent cost of their own</p><p>prosperity?753</p><p>Tobacco is one of our great public health victories. The share of adults</p><p>who smoke declined from 42 percent in 1965754 down to just 15 percent</p><p>today.755 That’s about five out of twelve down to fewer than two out of</p><p>twelve. Thanks to the decline, cigarettes now only kill about a half million</p><p>Americans a year, whereas our diets kill many thousands more. Currently,</p><p>the leading cause of death in America is the American diet.756</p><p>Might we be able to use the same strategies that were so successful in the</p><p>battle against Big Tobacco? It may be no coincidence that three of the most</p><p>cost-effective policy interventions against obesity seem to be taken straight</p><p>from the tobacco wars: (1) taxes on unhealthy products, (2) front-of-pack</p><p>labeling, and (3) a restriction on advertising to children.757</p><p>Death and Taxes</p><p>Excise taxes on cigarettes have been cited as the single most effective</p><p>weapon in slashing smoking rates.758 A twenty-five-cents-per-pack tax to</p><p>help deal with some of the societal costs of smoking was tied to as much as</p><p>a 9 percent decrease in smoking rates.759 The World Health Organization</p><p>has estimated that a 70 percent global increase in the price of cigarettes</p><p>could prevent up to a quarter of all tobacco-related deaths worldwide.760</p><p>Extending taxes on alcohol and tobacco to foodstuffs was proposed by</p><p>none other than Adam Smith in his 1776 Wealth of Nations: “Sugar, rum,</p><p>and tobacco, are commodities which are nowhere necessaries of life, which</p><p>are become objects of almost universal consumption, and which are,</p><p>therefore, extremely proper subjects of taxation.”761 People have the right to</p><p>smoke, drink, and eat fattening foods, the logic goes, but perhaps they</p><p>should help defray some of the publicly funded medical costs that result</p><p>from their unhealthy habits.762</p><p>A penny-per-ounce tax on sugar-sweetened beverages could bring in</p><p>more than a billion dollars a year in states like Texas and California.763 A 10</p><p>percent tax on fattening foods on a national level could yield half a trillion</p><p>dollars over ten years.764 Even if such a tax were combined with a subsidy</p><p>that lowered the cost of fruits and vegetables by 10 percent, it would be</p><p>expected to net hundreds of billions of dollars. But would it change</p><p>anyone’s eating habits? Just a small price differential of about 10 percent</p><p>between unleaded and leaded gas was able to shift the entire auto industry</p><p>away from lead.765 What we want to know now is whether such a price</p><p>difference could also shift Americans to apples from apple pie.</p><p>A systematic review of the available evidence suggests that dietary</p><p>financial incentives and disincentives do work. The cheaper we make fruits</p><p>and vegetables, the more people said they’d buy, and the more we tax</p><p>unhealthy foods, the lower their consumption drops.766 Based on this kind of</p><p>modeling, a tax on saturated fat (found mostly in fatty meat, dairy, and</p><p>junk) could potentially save thousands of lives a year.767</p><p>But wouldn’t such a tax disproportionately affect the poor? Yes, in that</p><p>we would expect the impoverished to benefit the most. It’s like cigarette</p><p>taxes.768 The classic tobacco industry argument is that cigarette taxes are</p><p>“unfair” and “regressive,” burdening the poor the most, to which the public</p><p>health community responded: “Cancer is unfair.” Indeed, cancer</p><p>disproportionately burdens the poor,769 so these types of taxes would be</p><p>expected to affect the greatest health gains for the least well-off.</p><p>The fact that the tobacco industry fought tooth and nail against cigarette</p><p>taxes—doing everything from inventing industry front groups to overtly</p><p>buying off politicians770—suggests that taxes can indeed be a powerful tool</p><p>to shift people’s habits, but much of the evidence on changing food</p><p>behaviors has not been based on real-life data. When people are put through</p><p>high-tech, 3-D supermarket simulators, researchers have shown that a 25</p><p>percent discount on fruits and vegetables appears to boost produce</p><p>purchasing by the same amount—up to nearly two pounds a week.771 Virtual</p><p>vegetables, however, don’t actually do you any good. Does this work in the</p><p>real world with real food?</p><p>South Africa’s largest private health insurer started offering up to 25</p><p>percent cash back on healthy food purchases to hundreds of thousands of</p><p>households, up to the U.S. equivalent of $799 per month.772 Why would the</p><p>insurer give money away? Because it apparently increases consumption of</p><p>fruits, vegetables, and whole grains, while at the same time decreasing</p><p>consumption of foods high in added sugar, salt, and fat, including processed</p><p>meats and fast food—which then would be expected to translate into</p><p>reduced disease rates, saving the insurer money.773</p><p>Why not just pay people to lose weight directly? A systematic review</p><p>found that eleven out of twelve studies on financial incentives for weight</p><p>loss described positive results.774 The one that failed to find a benefit of</p><p>direct monetary inducements had only offered $2.80 a day.775 With kids, you</p><p>can get away with just giving them a nickel or a sticker to get them to</p><p>choose dried fruit over a cookie as an afterschool snack, but as soon as the</p><p>enticements ended, so did the change in behavior.776</p><p>Even if the incentives have to be made permanent, they might still pay</p><p>for themselves. In the United States, every $1 spent taxing processed foods</p><p>or milk might net an estimated $2 in health-care cost savings. Every $1</p><p>spent making vegetables cheaper could net $3, and subsidizing whole grains</p><p>might offer more than a 1,000 percent return on investment.777 Even a 1</p><p>percent decrease in the average price of all fruits and vegetables might</p><p>prevent nearly ten thousand heart attacks and strokes every year.778</p><p>From Coke to Coors: Unintended</p><p>Consequences</p><p>Sometimes dietary policy decisions can have unintended consequences. Swapping out sugary</p><p>cookies for salty chips, for example, might not do the public’s health many favors. One field</p><p>study of a tax on soda found that it can drop soft drink purchases, but households may just end</p><p>up buying more beer.779 Another study found that, ironically, calorie labeling of sugary drinks</p><p>led to an increase in consumption, presumed to be because the consumers may have</p><p>previously overestimated their caloric content.780</p><p>Stark warnings about the risks of unintended, negative consequences of obesity-targeted</p><p>health policies are trumpeted by those with ties to the likes of Coca-Cola, Kraft, PepsiCo,</p><p>Wrigley, Red Bull, the World Sugar Research Organisation, the National Cattlemen’s Beef</p><p>Association, Mars, and corn syrup giant Archer Daniels Midland (and that is just a single</p><p>scientist’s list of funding sources).781 The concern shouldn’t paralyze our efforts, but it should</p><p>serve up a healthy dose of humility when considering policy proposals.782</p><p>How about releasing a video game for kids that promotes fruit? Sounds good, right? Well,</p><p>what do you think happened when kids were seated in front of bowls of fruit and candy, and</p><p>randomized to play one of three different computer “advergames” (advertising-game hybrids</p><p>incorporating product placements) that promoted either candy, fruit, or toys? The pro-candy</p><p>game group ate more candy, but, disappointingly, the pro-fruit group didn’t eat more fruit.</p><p>Then it got interesting. The kids in the pro-fruit group also ate more candy. Compared to the</p><p>pro-toy control group, having a kid play a</p><p>video game promoting fruit led them to eat more</p><p>candy. Presumably both the candy and fruit games just made the kids think about food, and</p><p>they naturally gravitated to their preferred snacks.783</p><p>Among the most fascinating phenomena I’ve come across is the boomerang effect of</p><p>“remedy messaging.” One might presume that the advertising of smoking cessation aids like</p><p>nicotine gum would help make quitting easier. After all, the vast majority of smokers want to</p><p>quit,784 so availing them of helpful options couldn’t help but help, right? Instead, such remedy</p><p>marketing can create a vicarious get-out-of-jail-free card that ends up reinforcing risky</p><p>behavior. Exposure to nicotine replacement product advertising was found to undermine</p><p>quitting intentions, especially among the heaviest smokers, the very ones who needed it the</p><p>most. The thought is that smokers may subconsciously interpret the remedy as evidence that</p><p>the hazards of smoking are more manageable and, therefore, less risky, which thereby helps to</p><p>justify their habit.785</p><p>You can see how easily this would translate to the weight-loss arena. We explored how</p><p>self-licensing could cause those taking slimming supplements to inadvertently eat more, but</p><p>merely being exposed to an ad for a “fat-fighting pill” appeared to have a similar type of</p><p>effect. So even when companies are ostensibly selling health rather than disease, they still may</p><p>be inadvertently making the problem worse. And in the marketplace, there’s just no incentive</p><p>for risk-avoidance messaging. Nobody makes money selling just say no unless it can</p><p>somehow be linked to salable products and services.786</p><p>A policy in France—where burgers now outsell baguettes787—may represent an interesting</p><p>real-world example of the counterintuitive remedy-messaging effect. Industry lobbying took a</p><p>valiant effort to ban the advertising of junk and morphed it into a mandate for preventive</p><p>health messaging on junk food advertisements.788 On products like Lay’s Chips Saveur Poulet</p><p>Rôti (chicken-flavored potato chips), you’ll now see messages like Pour votre santé, pratiquez</p><p>une activité physique régulière (For your health, practice regular physical activity).789</p><p>Sounds good, right? Not so fast. Anytime an industry agrees to a regulation, one should get</p><p>skeptical as to its effectiveness.</p><p>To see if such messaging might lead to a boomerang effect, research subjects were</p><p>randomized to view a Big Mac advertisement with or without the preventive health message</p><p>For your health, eat at least five fruits and vegetables per day. (After all, wouldn’t it be great</p><p>if McDonald’s were forced to advertise healthy food?) The subjects then filled out a general</p><p>questionnaire and, before they left, were allowed to choose one of two McDonald’s coupons</p><p>as a reward for their participation: a free sundae or a free bag of fruit.790 Guess who was more</p><p>likely to pick the fruit?</p><p>Only one in three who had just seen the straight burger advertisement, the one without the</p><p>preventive health message, chose the fruit over the sundae, but that number fell to only about</p><p>one in six among those who had been prompted to eat healthier.791 Isn’t that wild? The</p><p>absence of the healthy message doubled the number of people choosing the healthy snack.</p><p>The health message made things worse. This may be the remedy-messaging boomerang effect</p><p>in action. Simultaneously offering a temptation with a reminder about how they can dig</p><p>themselves out justifies the excuse to indulge. Subconsciously, it may give the chicken-y chip</p><p>eater the rationalization that they can just work it off the next day at the gym, even if that day</p><p>never comes.</p><p>The recommended antidote to avoid justification effects is to instead use negative</p><p>framing.792 That is, instead of offering a way out to compensate for indulging “just this one</p><p>time,” cautionary messages may be more effective. For example, imagine reading Pour votre</p><p>santé, évitez de manger trop gras, trop sucré, trop salé (For your health, avoid foods that are</p><p>too fatty, too sweet, or too salty) on your next chocolate-filled or ham-and-cheese croissant.</p><p>That’s a message for which I doubt Le McDonald’s would be quite as enthusiastic.</p><p>Truth in Advertising</p><p>A tried-and-true method used by alcohol, tobacco, and food-related</p><p>corporate interests to deflect attention away from health is to reframe</p><p>something like a fat tax or soda tax as an issue of freedom, railing against</p><p>the “nanny state” for restricting consumers’ rights.793 However, those</p><p>complaining about the governmental manipulation of people’s choices</p><p>hypocritically tend to be fine with corporations doing the very same</p><p>thing.794 Case in point: former New York City mayor Michael Bloomberg’s</p><p>attempt to cap soft drink sizes. How dare he try to manipulate consumer</p><p>choice! But isn’t that just what the industry’s done? In 1950, a twelve-ounce</p><p>soda was the “king-sized” option.795 Today, it’s marketed as a child’s</p><p>portion. “King-sized” became “kid-sized.”</p><p>The tobacco industry’s classic “personal responsibility” trope does have</p><p>a certain philosophical appeal.796 As long as people understand the risks,</p><p>shouldn’t they be free to do whatever they want with their bodies? Sure,</p><p>risk-taking affects others, but if you have the right to put your own life at</p><p>risk, shouldn’t you have the right to aggrieve your parents, widow your</p><p>spouse, and orphan your children?797 There is a social cost argument:</p><p>People’s bad decisions can cost society as a whole, and our tax dollars may</p><p>have to care for them. As some health law scholars eloquently put it, “The</p><p>independent individualist [motorcyclist], helmetless and free on the open</p><p>road, becomes the most dependent of individuals in the spinal injury</p><p>ward.”798</p><p>For the sake of argument, though, let’s forget these spillover effects. If</p><p>someone understands the hazards, shouldn’t they be able to do as they</p><p>please? This assumes consumers have access to accurate and balanced</p><p>information. How could smoking be a fully informed choice when tobacco</p><p>companies spent decades deliberately suppressing, manipulating, and</p><p>undermining the scientific evidence?799 “Don’t worry your pretty little</p><p>head,” said the nanny companies.</p><p>Is the food industry any different? We are bombarded with conflicting</p><p>nutrition messages.800 People love hearing good news about their bad habits,</p><p>so clickbait headlines like “Butter Is Back” may sell a lot of magazines, but</p><p>they sell the public short.</p><p>“It is not just Big Tobacco anymore,” declared the director-general of the</p><p>World Health Organization.801 “Public health must also contend with Big</p><p>Food, Big Soda, and Big Alcohol. All of these industries fear regulation,</p><p>and protect themselves by using the same tactics … front groups, lobbies,</p><p>promises of self-regulation, lawsuits, and industry-funded research that</p><p>confuses the evidence and keeps the public in doubt.” It’s like that infamous</p><p>tobacco industry memo that read: “Doubt is our product since it’s the best</p><p>means of competing with the body of fact that exists in the mind of the</p><p>general public.”802 The tobacco industry didn’t have to convince the public</p><p>that smoking was healthy to get people to keep consuming its products. It</p><p>just needed to establish a controversy: Some science says it’s bad, some</p><p>says it’s not so bad.</p><p>Conflicting messages in nutrition cause people to become so frustrated</p><p>and confused they may just throw their hands up in the air and eat</p><p>whatever’s put in front of them, which is exactly what the industry wants.</p><p>No purveyor of unhealthy products wants the public to know the truth.</p><p>An extraordinary example of this is the tobacco industry’s 1967 response to</p><p>the Fairness Doctrine. A court ruled that TV and radio stations had to run</p><p>one health ad about smoking for every four tobacco ads they ran. Rather</p><p>than risk the public being informed—even on a one-to-four basis—the</p><p>tobacco companies withdrew all their own advertising from television.803</p><p>They knew they couldn’t compete with the truth. They needed to keep the</p><p>public in the dark.</p><p>Now there are health warnings on each pack of</p><p>cigarettes. Global</p><p>travelers will notice, though, that while the U.S. mandate is met with</p><p>simple, black-and-white text, other countries plaster evocative images, such</p><p>as rotting gums, on their cigarette packs.804 Canadian smokers are forced to</p><p>look at a drooping cigarette with the caption TOBACCO USE CAN MAKE YOU</p><p>IMPOTENT. Similarly, U.S. food packaging just has the inscrutable bring-</p><p>your-calculator-to-the-grocery-store nutrition facts label on the back. I don’t</p><p>expect pictures of flaccid frankfurters, but other countries have tried to</p><p>impose clear and simple front-of-package graphics to convey the health</p><p>risks of fattening foods.805</p><p>“Signpost labeling” offers easy-to-understand traffic-light symbols</p><p>alerting shoppers to the salt, sugar, and saturated fat content of products</p><p>right on the front of every package.806 When it’s been tried, investment</p><p>analysts at Citibank concluded, “The magnitude of the sales impacts is such</p><p>that we are left with the inescapable conclusion that the increased</p><p>prevalence of front-of-pack signposts may lead to marked changes in</p><p>consumer buying habits.” It works so well that green, yellow, and red</p><p>traffic-light labeling poses “dire consequences” for certain food</p><p>categories.807 No wonder the food industry fought it fiercely, spending more</p><p>than a billion dollars to defeat it in Europe, an amount that’s ten times more</p><p>than the drug industry lobby spends annually in the United States.808</p><p>It’s in the food industry’s interest to have the public confused about</p><p>nutrition.</p><p>Vicarious Goal Fulfillment</p><p>What about labeling menus with calorie counts? Just as one might divine the significance of</p><p>front-of-pack signpost labeling from the ferocity of the industry response, one could probably</p><p>gauge the futility of calorie labeling by the ease at which such regulations have been passed.</p><p>McDonald’s voluntarily started doing it nationally in 2012809 after a labeling mandate in New</p><p>York City was found to have no overall effect on consumer behavior.810 Studies suggest such</p><p>voluntary labeling could boost “perceptions of the restaurant’s concern for customers’ well-</p><p>being,”811 while not stopping any Big Mac attacks.</p><p>At the same time, McDonald’s announced plans for adding seasonal produce to its</p><p>menu.812 How cynical do you have to be to not at least recognize that as a good thing? Well,</p><p>ironically, adding a healthy option can actually sway people to make even worse choices.</p><p>If you offer people with high self-control a choice of side dishes—something unhealthy</p><p>like french fries or something more neutral like a baked potato—only about 10 percent of</p><p>them will splurge for the fries. French fries are so unhealthy, though, that as a public health</p><p>do-gooder, you add a third option, an even healthier one—a side salad—to appeal to their</p><p>better natures. Even if they don’t choose the salad, perhaps more will elect the middle-ground</p><p>baked potato. So how much further does french-fry fancying fall by adding the salad option to</p><p>the mix? It shoots up to more than 50 percent. Without the salad option, only one in ten chose</p><p>the fries over the baked potato, but it jumped to more than half of the people just at the sight</p><p>of salad.</p><p>The same thing happens when you offer people the choice of a bacon cheeseburger, a</p><p>chicken sandwich, or a veggie burger. In a “No Healthy Option” scenario where people were</p><p>offered the bacon cheeseburger, a chicken sandwich, or a fish sandwich, 17 percent chose the</p><p>burger. When the fish sandwich was replaced with a veggie burger, however, the bacon</p><p>cheeseburger preference more than doubled, up to 37 percent. How can just seeing a healthy</p><p>option push people to make unhealthier choices? The title given to the paper describing these</p><p>series of experiments is “Vicarious Goal Fulfillment: When the Mere Presence of a Healthy</p><p>Option Leads to an Ironically Indulgent Decision.” The thinking is that just by seeing the</p><p>salad or plant-based option, people make the mental note to choose that the next time, thereby</p><p>giving them the excuse to indulge now. Remember the self-licensing effect, where people</p><p>making progress toward a goal rationalize making decisions that undermine it? These</p><p>experiments suggest that even merely considering making progress can have a similar</p><p>licensing effect.813</p><p>Note that the study participants weren’t just moved to make the unhealthier choice, but the</p><p>unhealthiest one. Even if people don’t go for the salad or veggie burger option, you’d think</p><p>that the presence of a healthier alternative might, at the very least, encourage people to choose</p><p>something in between. Instead, it moved people in the opposite direction altogether. Compared</p><p>to the “No Healthy Option” scenario of chocolate-covered Oreos, regular Oreos, or golden</p><p>Oreos, adding a “lower-calorie” Oreo option doubled the likelihood study participants would</p><p>go straight for the most indulgent chocolate-covered option. This is attributed to another</p><p>illogical quirk of human psychology, the indelicately named what-the-hell effect. This is when</p><p>one forbidden cookie can lead dieters to eat the whole bag. Once you’ve already strayed from</p><p>your goals, why not go all the way? So once people decide they are going to get the salad the</p><p>next time and spoil themselves “just this once,” they might as well go for the most indulgent</p><p>choice.814</p><p>The halo of healthy foods can even warp our perceptions. When weight-conscious people</p><p>were shown a burger on its own and asked to estimate its calories, the average answer was 734</p><p>calories. What happened when people were shown the exact same burger, but this time, it was</p><p>accompanied by three celery sticks? The estimated number of calories dropped to 619. Did</p><p>they think the celery had negative calories? No, most knew the celery had calories, too, but</p><p>just the juxtaposition made the burger seem healthier. The same thing happens when you add</p><p>an apple next to a bacon-and-cheese waffle sandwich, a side salad to beef chili, or some</p><p>carrots next to a cheesesteak. About one hundred calories appear to disappear.815 Health halo</p><p>effects may explain why people are more likely to order a dessert and more sugary drinks with</p><p>a “healthier” sub at Subway versus a Big Mac at McDonald’s, even though the sub used in the</p><p>study (filled with ham, salami, and pepperoni) had 50 percent more calories than the Big</p><p>Mac.816</p><p>Even just a reference to healthy foods can cause this unhealthy behavior. Remember that</p><p>crazy Big Mac study where the eat-your-fruits-and-veggies message steered people toward the</p><p>sundae instead of the fruit? The findings get even wackier. When asked to estimate the calorie</p><p>content of the burger pictured in the ad without any health messaging, people guessed 646</p><p>calories.817 What happened when the text For your health, eat at least five fruits and</p><p>vegetables per day was added to the ad? All of a sudden, the same burger in the same ad</p><p>appeared to only have 503 calories. So offering and even promoting salads and fruit can bring</p><p>McDonald’s accolades and bolster consumer loyalty without, ironically, helping their</p><p>waistlines.818</p><p>Ad Nauseam</p><p>The third strategy taken from the anti-tobacco playbook, after taxes and</p><p>front-of-pack labeling, is restricting advertising to children.819 The food</p><p>industry spends more money on advertising than any other industry,820 with</p><p>more than $10 billion in ads targeting American children and teens every</p><p>year.821 As a case study example, allow me to profile the number-one food</p><p>advertised to kids: breakfast cereals.</p><p>There have been calls for nearly a half century to ban the advertising of</p><p>sugary cereals to children, which Harvard nutrition professor Jean Mayer</p><p>referred to as “sugar-coated nothings.”822 In a Senate hearing on nutrition</p><p>education, he said, “Properly speaking, they ought to be called cereal-</p><p>flavored candy, rather than sugar-covered cereals.”823</p><p>The Senate committee had invited the major manufacturers of children’s</p><p>cereals to testify. They initially agreed to participate—until they heard the</p><p>kinds of questions that were going to be asked. One cereal industry</p><p>representative candidly admitted why he decided to boycott the hearing: He</p><p>simply didn’t have “persuasive answers” for why the industry tries to sell</p><p>kids candy for breakfast.824</p><p>In the Mad Men age before the consumer movement was in bloom,</p><p>advertising company executives were more willing to talk frankly about the</p><p>purpose of their ads and how they felt about aiming them at the “child</p><p>market.”825 For example, consider this 1965 quote from an ad executive for</p><p>Kellogg’s and Oscar Mayer:</p><p>Our primary goal is to sell products to children, not educate them.</p><p>When you sell a woman a product and she goes in to the store and</p><p>finds your brand isn’t in stock, she will probably forget about it. But</p><p>when you sell a kid on your product, if he can’t get it, he will throw</p><p>himself on the floor, stamp his feet and cry. You can’t get a reaction</p><p>like that out of an adult.826</p><p>To preempt federal regulations, the industry pledged to self-regulate and</p><p>launched the Children’s Food and Beverage Advertising Initiative, in which</p><p>all the big cereal companies promised they would only market healthier</p><p>dietary choices to kids.827 The candy industry signed on too. How did that</p><p>go? Well, how do you think it went? They pledged not to advertise to</p><p>children, yet after the initiative went into effect, kids actually saw more</p><p>candy ads. Hershey, for example, more than doubled its advertising to</p><p>children, while, at the same time, pledging not to advertise to children at</p><p>all.828</p><p>The cereal companies got to decide for themselves their own definitions</p><p>of “healthier dietary choices,” and what they chose should give a sense of</p><p>how serious they are about protecting children: They classified Froot Loops</p><p>and Reese’s Peanut Butter Puffs, which consist of up to 44 percent sugar by</p><p>weight, as “healthier dietary choices.”829 In that case, what are their</p><p>unhealthy choices?! Rather than base it on what might be best for children,</p><p>they basically set the limit based more on the sugar content of everything</p><p>they were already selling.830</p><p>The industry has since revised the “healthier dietary choices” criteria to</p><p>allow only cereals that are below 38 percent sugar by weight.831 Even if</p><p>they’re “only” one-third sugar, that means kids effectively are eating at least</p><p>one spoonful of sugar in every three spoonfuls of cereal.832 I wouldn’t call</p><p>that a healthy dietary choice.</p><p>The Federal Trade Commission (FTC) tried stepping it back in 1978, but</p><p>industry poured in millions to fight it, and, with enough campaign</p><p>contributions, Congress essentially threatened to yank the entire agency’s</p><p>funding if it continued to pursue industry regulations.833 This demonstrated</p><p>to a former CDC nutrition director “just how powerful market forces are</p><p>compared to those that can be mobilized on behalf of children.”834 The</p><p>political post-traumatic stress induced by the industry backlash delayed</p><p>further federal efforts to rein in food marketing aimed at children for</p><p>decades.</p><p>But then, enter the Interagency Working Group.835 In 2011, FTC, CDC,</p><p>FDA, and U.S. Department of Agriculture (USDA) all came together to</p><p>propose voluntary principles designed to encourage stronger and more</p><p>meaningful self-regulation. Their radical suggestion? Don’t market cereal</p><p>that is more than 26 percent sugar to children.836</p><p>Not a single one of the top ten breakfast cereals marketed to children</p><p>would meet that standard.837 General Mills shot back that the proposed</p><p>nutrition standards were “arbitrary, capricious, and fundamentally flawed.”</p><p>After all, it pleaded, “literally all cereals marketed by General Mills would</p><p>be barred from advertising.”838 One grocers’ association called the proposed</p><p>nutrition principles the “most bizarre and unconscionable” it had ever</p><p>seen.839 Cereal manufacturers charged that the suggested recommendations</p><p>for voluntary self-regulation would unconstitutionally violate their “free</p><p>speech rights” under the First Amendment,840 to which the FTC basically</p><p>offered to get them a dictionary so they could look up the meaning of the</p><p>word voluntary.841 All this gives you a sense of how freaked out the food</p><p>industry got at even the notion of meaningful guidelines.</p><p>So what happened? Again, agency funding was put into jeopardy, so the</p><p>interagency proposal was called off.842 “We just got beat,” one of the child</p><p>advocacy organizations said. “Money wins.” It apparently took $175</p><p>million of Big Food lobbying to buy the White House’s silence as the</p><p>interagency proposal got killed. As one Obama adviser put it, “You can tell</p><p>someone to eat less fat, consume more fiber, more fruits and vegetables and</p><p>less sugar. But if you start naming foods, you cross the line.”843</p><p>“I’m upset with the White House,” the chair of the Senate Health</p><p>Committee said.844 “They went wobbly in the knees, and when it comes to</p><p>kids’ health, they shouldn’t go wobbly in the knees.”</p><p>How We Won the Trans Fat Fight</p><p>In 2012, a prize-winning845 exposé on corporate lobbyists found that the</p><p>food and beverage industries had never lost a significant political battle in</p><p>the United States, winning fight after fight at every level of government.846</p><p>That all changed in 2018 with the successful ban on added trans fat in the</p><p>American food supply. Trans fat, found largely in vegetable oils partially</p><p>hydrogenated to mimic the qualities of animal fats in snack foods, was</p><p>implicated in the deaths of tens of thousands of Americans every year.847 So</p><p>how did the public health movement finally triumph?</p><p>There are three broad approaches to mediating the ruin of risky choices:</p><p>inform people (such as through labeling), nudge people (perhaps with</p><p>financial incentives), or directly intervene to make the activity less</p><p>harmful.848 Which do you think prevented more car fatalities: mandating</p><p>driver education, labeling cars about crash risk, or removing the human</p><p>element by just making sure airbags are installed?849 There are public</p><p>education nutrition campaigns—from “sugar pack” ads on public transit</p><p>informing consumers how much sugar there is in soft drinks850 to “Hot</p><p>Dogs Cause Butt Cancer” billboards educating people about the link</p><p>between processed meat and colorectal cancer.851 But just warning people</p><p>about trans fat wasn’t working.</p><p>We learned about the dangers of trans fat in 1993, when the Harvard</p><p>Nurses’ Health Study reported that high intake of trans fat may increase the</p><p>risk of heart disease by 50 percent.852 That’s where the trans fat story started</p><p>in Denmark—a story that ended a decade later with a ban on added trans fat</p><p>in 2003.853 It took another ten years before the United States even started</p><p>considering a ban.854 All the while, trans fat continued to kill the estimated</p><p>tens of thousands of Americans every year,855 resulting in as many years of</p><p>healthy life lost as conditions like meningitis, cervical cancer, and multiple</p><p>sclerosis.856 If so many people were suffering and dying, why did it take so</p><p>long for the United States to even suggest taking action?</p><p>One can look at the fight over New York City’s trans fat ban for a</p><p>microcosm of the national debate. Opposition came down hard from the</p><p>food industry, complaining about “government intrusion” and likening the</p><p>city to a “nanny state.”857 The livestock industries echoed858 the everything-</p><p>in-moderation argument made by the Institute of Shortening and Edible</p><p>Oils859 (since trans fat is present naturally in meat and dairy).860 Another</p><p>argument went: If “food zealots” get their wish in banning added trans fat,</p><p>what’s next?861 Critics styled proposals for a trans fat ban as the “rise of</p><p>food fascism,”862 but it was really the restaurant and food industry that was</p><p>limiting consumer choice, by so broadly fouling the food supply with these</p><p>dangerous fats.863</p><p>Vested corporate interests tend to rally around these kinds of “slippery</p><p>slope” arguments to distract from the fact that people are dying.864 What if</p><p>the government tries to make us eat broccoli? Unbelievably, that actually</p><p>came up in a Supreme Court case over Obamacare. Chief Justice Roberts</p><p>suggested Congress could start “ordering everyone</p><p>to buy vegetables,” a</p><p>fear Justice Ginsburg dubbed “the broccoli horrible.” Technically, Congress</p><p>could compel the American public to eat more plant-based, Justice</p><p>Ginsburg wrote, yet one can’t “offer the ‘hypothetical and unreal</p><p>possibilit[y]’ … of a vegetarian state as a credible [argument].”865 As one</p><p>legal scholar put it, “Judges and lawyers [may] live on the slippery slope of</p><p>analogies; [but] they are not supposed to ski it to the bottom.”866</p><p>But New York City eventually won its trans fat fight in 2006, preserving</p><p>its status as a public health leader. New York, for example, banned lead</p><p>paint eighteen years before federal action was taken despite decades of</p><p>unequivocal evidence for harm.867 Comparing stroke and heart attack rates</p><p>before and after the rollout of the trans fat ban in different New York</p><p>counties, researchers estimate the ban successfully reduced cardiovascular</p><p>death rates by about 5 percent.868 This then became the model for the</p><p>nationwide ban in 2018.</p><p>How was public health able to triumph when past attempts to regulate</p><p>the food industry failed? If you would have asked me back then about the</p><p>odds of a trans fat ban, I would have answered: Fat chance.</p><p>In Denmark, as a leading Danish cardiologist put it, “Instead of warning</p><p>consumers about trans fats and telling them what they are, we’ve simply</p><p>removed them.” The cardiologist continued, “As they say in North</p><p>America, ‘You can put poison in food if you label it properly.’”869 And in</p><p>America, things do seem to work differently. The belief is if people know</p><p>the risks, they should be able to eat whatever they want—but that’s</p><p>assuming they’re given all the facts. Unfortunately, this isn’t always the</p><p>case, especially given the food industry’s “model of systemic dishonesty,”</p><p>as one health ethics professor put it.870</p><p>Because of the predilection for predatory deception and manipulation,</p><p>government intervention was deemed necessary when it came to trans fat.</p><p>But how did the ban get passed? First there was a labeling requirement.</p><p>Manufacturers had to start adding trans fat content to the nutrition facts</p><p>labels. This ostensibly was to influence consumers, but it may have had a</p><p>bigger impact on producers. Now that they had to divulge the truth,</p><p>companies scrambled to reformulate their products to gain a “no trans fat”</p><p>competitive edge.</p><p>Within a year of the mandatory disclosure, more than five thousand</p><p>products were introduced touting low or zero trans fat on their labels.871</p><p>Kentucky Fried Chicken went from being sued for having some of the</p><p>highest trans fat levels872 to running an ad campaign where the mom tells</p><p>the dad in front of the kids that KFC now has zero grams of trans fat. The</p><p>father yells, “Yeah, baby! Whoooo!”—and begins eating fried chicken by</p><p>the bucketful.873 That was the secret to passing the ban. Once the major food</p><p>industry players had already reformulated their products and bragged about</p><p>it, once there wasn’t so much money at stake, then there was insufficient</p><p>political will to block the ban.</p><p>Leveling the Playing Field</p><p>Even without regulations, the market can be rapidly responsive, but only</p><p>within certain parameters. The gluten-free craze is a great example. Ten</p><p>years ago, how many people had even heard the word gluten? And now,</p><p>some surveys suggest as many as 25 percent of the population is trying to</p><p>avoid it.874 This has led to an explosion of more than ten thousand products</p><p>labeled as gluten-free,875 including ones from major players, such as Tyson</p><p>Foods launching gluten-free bacon and lunch meat.876 Ironically, gluten-free</p><p>products may be less healthy, with more sugar and salt, less fiber, and fewer</p><p>nutrients, so they’re mostly just different shades of the same processed</p><p>junk.877 A gluten-free donut is still a donut. And a nutritional analysis of</p><p>foods marketed to children found that about 90 percent of products—both</p><p>gluten-free and not—were classified as “unhealthy.”878</p><p>That’s the limit of the market. The invisible hand is more than happy to</p><p>hand us any kind of junk we want—from SnackWell’s to keto cookies. The</p><p>industries can make money off any fad, except real food. Shareholders can</p><p>profit off any kind of Funyuns but can’t do much with real onions. Within a</p><p>narrow scope of commodity components and chemicals, endless</p><p>reformulations can fit any fashionable flavor of the month, but produce will</p><p>never be as profitable.</p><p>The market even prevents food manufacturers from taking small steps to</p><p>make their products less detrimental, such as lowering salt or sugar content.</p><p>Any deviation from the levels perfectly engineered for maximum</p><p>craveability could get you immediately undercut by your competitors. How</p><p>then was England able to so successfully lower sodium intake, which has</p><p>been associated with dramatic drops in stroke and heart disease deaths?879</p><p>Because it was done across the board. McDonald’s Chicken McNuggets</p><p>have two and a half times more salt in the United States than in the United</p><p>Kingdom, but that’s because Burger King UK was cutting down too.880</p><p>In the best-documented population-level sodium reduction to date,881 the</p><p>British government formed public-private partnerships with major food</p><p>manufacturers, retailers, and restaurant chains to simultaneously reduce</p><p>sodium levels so slowly over the years that no one would notice.882 The</p><p>secret sauce may be the level playing field, so no company could gain a</p><p>commercial advantage by outsalting competitors.883 Analogous proposals</p><p>have called for the stepwise, gradual, unobtrusive reduction in sugar in soft</p><p>drinks to effect a similar shift in taste preferences on a population-wide</p><p>scale.884</p><p>If this all sounds a bit Big Brother-y, realize that people can still season</p><p>and sweeten to their heart’s desire (or rather, detriment). Salt your nuggets</p><p>all you want. Dump the whole shaker on them and wash it down with a</p><p>bottle of corn syrup—it’s still your body, your choice. It’s like the proposed</p><p>cap on soft drink sizes. You can still drink all the soda you want. The idea is</p><p>just to try to make the default options a little healthier. It’s easier to add salt</p><p>to food on your plate than it is to remove it.</p><p>The lifesaving success of the trans fat ban and society-wide sodium</p><p>reduction may lie in the convenience of improving consumers’ diets</p><p>without them having to change their behaviors.885 Some view this as</p><p>government overreach, but the slipperiest slope may be that of inaction. As</p><p>the director of the Rudd Center for Food Policy and Obesity has pointed</p><p>out, governments initially defaulted to business interests in the case of</p><p>tobacco to try to counter all the industry lies with weak and ineffective</p><p>attempts at consumer education. And look what happened: “The</p><p>unnecessary deaths could be counted in the millions,” he wrote. “The U.S.</p><p>can ill afford to repeat this mistake with diet.”886</p><p>Until the political will is summoned to make industry-wide changes in</p><p>our food supply, we need to take personal responsibility for our own health</p><p>and for our families’ health because it looks to be a matter of life and death.</p><p>So what does that best personal solution look like in the interim? That’s</p><p>what the rest of this book is all about.</p><p>II. Ingredients for the Ideal Weight-</p><p>Loss Diet</p><p>INTRODUCTION</p><p>Fad Diet du Jour</p><p>The $50 billion weight-loss industry has been fed by an endless parade of</p><p>fad diets offering quick-fix solutions. Dr. David L. Katz said it well, as he</p><p>so often does: “In a market where buyers reject the tried and true in favor of</p><p>false promises and pixie dust and in a culture where scapegoats and silver</p><p>bullets are preferred over a prosaic blend of science and sense, the sellers</p><p>respond accordingly.”887 Indeed, Amazon now lists more than thirty</p><p>thousand weight-loss books.888</p><p>One of the defining characteristics of fad diets is their reliance on</p><p>testimonials rather than scientific evidence,889 but what’s particularly</p><p>insidious, beyond the nonsense and nonscience, is the pseudoscience—</p><p>when the trappings of science are used to gain a false air of legitimacy.</p><p>Confident, perhaps,</p><p>that no one will actually check, some diet book authors</p><p>(or likely their ghostwriters) cite scientific studies that either don’t support</p><p>their thesis or, at the very least, fail to accurately represent the best available</p><p>balance of evidence.</p><p>When people have taken the time to check the primary sources, it is</p><p>often to devastating effect.890 See, for example, Seth Yoder’s footnote-by-</p><p>footnote review of The Big Fat Surprise on his blog, The Science of</p><p>Nutrition.891 Similarly, when researchers looked through The South Beach</p><p>Diet, they didn’t just find a few mistakes: Two-thirds of the nutrition “facts”</p><p>they checked did not appear to be supported by peer-reviewed science.892</p><p>You can always sell more books offering people good news about their bad</p><p>habits, but at what human cost?</p><p>It’s worth repeating that every penny I receive from all my books is</p><p>donated directly to charity. It’s written right into my publishing contracts.</p><p>My overriding motivation is to provide the most accurate information</p><p>possible. I’m such a stickler for veracity that I hired nine fact-checkers to</p><p>go through every citation of the How Not to Die manuscript, and I</p><p>committed to the same rigor with this book.</p><p>My original intention with How Not to Diet, consonant with the title, was</p><p>to have chapters offering critical analysis on each of the leading popular</p><p>diets, but I realized that would be like playing a game of Whac-A-Mole.</p><p>I’m a member of the U.S. News & World Report Best Diets expert panel,</p><p>tasked with scoring dozens of trending diets based on set criteria, and so</p><p>I’m especially aware how many new diets pop up every year. I didn’t want</p><p>this book to be out of date before it even came out.</p><p>Thus, rather than taking a reactionary tactic and wasting page space on</p><p>Dr. Quack’s here-today-gone-tomorrow New Snake Oil Diet (now with</p><p>added tricksy pixie dust!), I decided upon a more timeless, proactive</p><p>approach: build an optimal weight-loss diet from the ground up. Based on</p><p>the most compelling evidence my research team and I could find, I sought</p><p>to generate a list of dietary attributes and components most effectual for</p><p>weight loss. The best ingredients, if you will.</p><p>I’ve distilled this research into a list of seventeen key ingredients for an</p><p>ideal weight-loss diet, which we’ll explore one by one over the course of</p><p>part II. These components can then be used to construct a portfolio of</p><p>dietary changes to attack excess body fat on multiple fronts, as well as offer</p><p>a template by which to compare any new diet that comes down the pike.</p><p>Many popular diets exist in an evidence-free zone powered by personal</p><p>biases and aggrandizement, free from the bonds of scientific</p><p>accountability.893 A few large proprietary programs have been put under</p><p>scientific scrutiny, though. So before we build an ideal weight-loss diet</p><p>from scratch, let’s briefly assess the current state of affairs.</p><p>Anecdotes as Evidence</p><p>Most Americans have tried to lose weight at some point in their lives, and</p><p>as many as around one in three is actively making the attempt at any given</p><p>moment.894 This has spawned a massive weight-loss industry valued at more</p><p>than $50 billion.895 With so much money at stake, it comes as no surprise</p><p>that there are so many different flavors of snake oil on tap. The history of</p><p>weight-loss quackery includes everything from body jigglers to suction-</p><p>cupped rolling pins. There was the Relax-a-cizor, an ironic name for a</p><p>device that delivers electric shocks,896 and wearing the Fat-Be-Gone ring</p><p>promised the “same benefits as jogging up to six miles per day”!897</p><p>“Unwanted pounds and inches scrub right off” with the Amazing Seaweed</p><p>Weight Loss Soap,898 and don’t forget the “amazing new super-formula”</p><p>that will “overwhelm fat like Cary Grant overwhelmed your</p><p>grandmother!”899</p><p>A major conclusion of congressional hearings on fraud in the diet</p><p>industry was that the entire sector was characterized by deceptive and</p><p>misleading advertising, rife with puffed-up promises.900 In an analysis of</p><p>hundreds of weight-loss advertisements, the FTC found that most ads made</p><p>at least one claim that was very likely to be false or, at the very least,</p><p>lacking adequate substantiation. Some were “grossly exaggerated,”</p><p>“obviously false claims” that were simply not “physiologically possible,”</p><p>like the product that guaranteed weight-loss efficacy comparable to</p><p>“running a 20 mile marathon while you sleep.” And it appears to be getting</p><p>even worse. Compared to a similar analysis of ads in the 1990s, the FTC</p><p>noted a “downward spiral to deception in weight-loss advertising.”901 The</p><p>FTC has recovered millions for conned consumers, but a law journal article</p><p>described the agency’s actions as a “mere slap on the wrist” for an industry</p><p>worth billions.902</p><p>By 2001, nearly 80 percent of all ads for weight-loss products or</p><p>programs featured at least one testimonial.903 Who doesn’t love a good</p><p>story?904 Scientists often assert “anecdotes aren’t data,” but human nature</p><p>may favor the opposite view—numbers are nice, but narratives can carry</p><p>more meaning. Fund-raisers know this. They know to tug at the heart, not</p><p>the head. It may not be surprising that people are more willing to donate to</p><p>an African relief program after hearing a story of a starving little girl rather</p><p>than give to an appeal outlining the dry statistics of the millions in need.</p><p>But what is surprising is that when both the story and the stats are put</p><p>together in the same appeal, people donate less than if they had heard just</p><p>the anecdote.905 We are notoriously prone to embracing anecdotal</p><p>evidence,906 and dietary hucksters rarely fail to exploit this hardwired</p><p>human instinct.907</p><p>Researchers have compared the weight-loss claims of commercial</p><p>programs to the actual results obtained from randomized controlled trials.</p><p>Weight Watchers, for example, featured a testimonial of a woman who lost</p><p>more than two hundred pounds after two years on the program908—but</p><p>when Weight Watchers was actually put to the test, the average weight loss</p><p>after two years was more like six pounds.909 The Weight Watchers watched</p><p>a lot more weight stay on than come off.</p><p>The Atkins website boasted a three-hundred-pound weight-loss</p><p>testimonial, and Jenny Craig a four-hundred-pounder. The average</p><p>advertised testimonial weight loss across twenty different programs was</p><p>about fifty pounds, a number far in excess of what even the programs’ own</p><p>published trials have shown.910 Even if the rare testimonial were true, we</p><p>almost never hear what happens next. When researchers actually followed</p><p>up on some of the people portrayed in the before-and-after pictures, only</p><p>about one in four had sustained their success.911 The commercial diet</p><p>program that participated in this study must have suspected as much, as its</p><p>cooperation with researchers was predicated on the stipulation that the</p><p>program never be identified.912 This is consistent with the findings of the</p><p>Deception and Fraud in the Diet Industry hearings in Congress that</p><p>concluded most programs actively suppress facts about what to expect</p><p>regarding chances of success.913</p><p>Programmed to Fail?</p><p>Many real-world diet trials are small in size and short in duration, and most</p><p>lack control groups and fail to follow through on weight loss over time.914</p><p>However, there are exceptions. Americans spend billions a year on</p><p>commercial weight-loss programs, such as Weight Watchers, Nutrisystem,</p><p>and Jenny Craig, and to their credit, these companies have spent some of</p><p>their largesse on efficacy research to try to promote their respective</p><p>programs.915 Nevertheless, the results of their own studies are</p><p>underwhelming.</p><p>A systematic review was conducted of randomized controlled trials of</p><p>commercial weight-loss programs that used exchange-based meal plans like</p><p>Weight Watchers, prepackaged meals like Jenny Craig, or meal</p><p>replacements like SlimFast. All in all, the majority of people enrolled in</p><p>these commercial weight-loss programs failed to achieve even a modest</p><p>weight loss, defined as a 5 percent reduction of their initial body weights</p><p>(for example,</p><p>a ten-pound loss for someone weighing two hundred</p><p>pounds).916</p><p>On average, so little weight was lost on these types of programs that cost</p><p>estimates range up to nearly $200 per pound lost.917 Most people don’t</p><p>chalk up that high of a bill, though, because most don’t stick with the</p><p>program for very long. For example, a study of more than sixty thousand</p><p>men and women enrolled in Jenny Craig found that fewer than 7 percent</p><p>remained at the end of one year.918 The largest, longest, best-designed</p><p>randomized trial of a commercial program was funded by Weight</p><p>Watchers,919 and after two years, the best it could show was an average</p><p>weight loss of only about 3 percent compared to a “self-help” control group</p><p>given informational resources and a couple of nutrition counseling</p><p>sessions.920 Imagine all that time and energy spent in weekly Weight</p><p>Watchers meetings to lose only an average of about three pounds a year.</p><p>Programs that include group sessions offer the advantage of social</p><p>support and accountability,921 but since some of the plans from leading</p><p>companies seem to result in similar weight loss,922 one might as well choose</p><p>the least expensive. Take Off Pounds Sensibly (TOPS) is a nonprofit, peer-</p><p>led weight-loss program that has been publishing its results for more than</p><p>fifty years.923 Not having to siphon off money for shareholders, TOPS is</p><p>five times cheaper than Weight Watchers and may be fifty times less</p><p>expensive than other leading programs such as Nutrisystem or Jenny</p><p>Craig.924</p><p>TOPS was the first national program to publish data on all its</p><p>completers. Only a tiny percentage stayed enrolled over the entire seven-</p><p>year study period, but the thousands who did maintained about an eighteen-</p><p>pound weight loss.925 Still, that only amounts to a few pounds a year. Is that</p><p>the best we can do? Sadly, as one obesity research pioneer once put it,</p><p>“Most obese persons will not stay in treatment for obesity. Of those who</p><p>stay in treatment, most will not lose weight, and of those who do lose</p><p>weight, most will regain it.”926</p><p>As a physician, my priority is getting (and keeping) people healthy, but</p><p>when people are surveyed about their motivation for dieting, disturbingly,</p><p>“health” may come in last.927 Dieters want results—they want weight to</p><p>come off.</p><p>So that became my challenge. If I were to construct the ideal weight-loss</p><p>diet, what characteristics would it have? My research team and I dove</p><p>headfirst into the nearly half-million papers published in the English-</p><p>language peer-reviewed medical literature on weight management and</p><p>certainly ran into some surprises on the way. What follows is our distilled</p><p>list of seventeen key ingredients—dietary attributes that could be used to</p><p>create the most effective eating plan for losing weight.</p><p>ANTI-INFLAMMATORY</p><p>Meta-Inflammation</p><p>One of the most important medical discoveries in recent years was the</p><p>realization that inflammation appears to play a role in many of our chronic</p><p>diseases, including at least eight of our top ten leading causes of death.928</p><p>The significance of this new understanding has been compared to the</p><p>discovery of the germ theory, which, centuries ago, revolutionized our</p><p>prevention and treatment of infectious diseases.929 Throughout most of</p><p>human history, however, inflammation was considered to be a good thing.</p><p>When you get a splinter in your finger and it gets red, hot, painful, and</p><p>swollen, that’s inflammation. It’s your body’s natural reaction to tissue</p><p>damage or irritation. So if the point of inflammation is to trigger the healing</p><p>process, not a disease process, what’s going on?</p><p>That splinter reaction is an example of acute inflammation, a short-term,</p><p>localized, specific response to infection or injury aimed at resolving a</p><p>problem. In contrast, chronic inflammation, also called metabolic</p><p>inflammation, or meta-inflammation for short, is persistent, systemic, and</p><p>nonspecific, and it appears to perpetuate disease.930 It has a low-grade,</p><p>smoldering quality—it’s not as though we’re red, hot, pained, and swollen</p><p>all over. Simple blood tests, however, can detect abnormally high levels of</p><p>inflammatory markers like C-reactive protein so that we can gauge our level</p><p>of chronic inflammation.</p><p>C-reactive protein levels in the blood are ideally under 1 mg/L,931 but in</p><p>the presence of an infection, they can jump to 100 mg/L or more within</p><p>hours.932 Now that we have highly sensitive C-reactive protein blood tests</p><p>that can measure levels to a fraction of a point, the medical community has</p><p>realized that walking around with baseline levels of even just 2 or 3 mg/L</p><p>appears to set us up for increased risk of catastrophes like heart attacks and</p><p>strokes.933 Having a C-reactive protein level under 1 mg/L denotes low risk,</p><p>yet the levels of most middle-aged Americans exceed this,934 suggesting</p><p>most suffer from chronic inflammation.</p><p>This widespread meta-inflammation appears to be our immune systems’</p><p>reaction to many unhealthy aspects of our lives—from the broader</p><p>environment like traffic pollution and toxic chemicals to our day-to-day</p><p>lifestyle choices, such as cigarettes, chronic stress, and too little physical</p><p>activity and sleep.935 The primary driver of meta-inflammatory chronic</p><p>disease, however, may be the portions of the outside world we introduce</p><p>into our bodies multiple times a day: what we eat.936</p><p>The Dietary Inflammatory Index</p><p>It’s easy to tell if a food is pro-inflammatory or anti-inflammatory: Feed it</p><p>to people, and see what happens to their levels of C-reactive protein and</p><p>other markers of inflammation. With this method, you can check the impact</p><p>of individual nutrients, whole foods, meals, or entire dietary patterns.</p><p>To rate people’s diets, researchers developed a Dietary Inflammatory</p><p>Index by scouring thousands of such experiments to come up with a scoring</p><p>system.937 The more pro-inflammatory foods you eat on a daily basis, the</p><p>higher your score, and the more anti-inflammatory foods you eat, the lower</p><p>your score. If you eat more anti-inflammatory than pro-inflammatory foods</p><p>overall, you could end up with the goal—a net negative score, an anti-</p><p>inflammatory diet.</p><p>Broadly speaking, components of processed foods and animal products,</p><p>such as saturated fat, trans fat, and cholesterol, were found to be pro-</p><p>inflammatory, while constituents of whole plant foods, such as fiber and</p><p>phytonutrients, were strongly anti-inflammatory.938 No surprise, then, that</p><p>the Standard American Diet rates as pro-inflammatory and has the elevated</p><p>disease rates to show for it.</p><p>Higher Dietary Inflammatory Index scores are linked to a higher risk of</p><p>cardiovascular disease939 and lower kidney,940 lung,941 and liver function.942</p><p>Those eating diets rated as more inflammatory also experienced faster</p><p>cellular aging.943,944 In the elderly, pro-inflammatory diets are associated</p><p>with impaired memory945 and increased frailty.946 Inflammatory diets are</p><p>also associated with worse mental health, including higher rates of</p><p>depression, anxiety, and impaired well-being.947 Additionally, eating more</p><p>pro-inflammatory foods has been tied to higher prostate cancer risk in</p><p>men948,949,950 and higher risks of breast cancer,951,952 endometrial cancer,953</p><p>ovarian cancer,954 and miscarriages in women. Higher Dietary Inflammatory</p><p>Index scores are also associated with more risk of esophageal,955 stomach,956</p><p>liver,957 pancreatic,958 colorectal,959 kidney,960 and bladder961 cancers, as well</p><p>as non-Hodgkin lymphoma.962</p><p>Overall, eating a more inflammatory diet was associated with 75 percent</p><p>increased odds of having cancer and 67 percent increased risk of dying</p><p>from cancer.963 Not surprisingly, those eating more anti-inflammatory diets</p><p>appear to live longer lives.964,965,966,967 But how does the Dietary</p><p>Inflammatory Index impact body weight?</p><p>Obesity and Inflammation: Cause or Consequence?</p><p>Pro-inflammatory diets are also associated with obesity, especially</p><p>abdominal obesity.968 When researchers followed thousands of normal-</p><p>weight adults over time, they found those eating more pro-inflammatory</p><p>foods have higher</p><p>of body fat.</p><p>It’s not only what we eat but how and when.</p><p>And the same number on the scale can mean different things on different</p><p>diets or in different contexts. You could be losing weight but actually</p><p>gaining body fat if your body sheds water and muscle mass. So it’s not just</p><p>about calories in versus calories out, eating less, and moving more. We’ll</p><p>see an illustration of this later, with a famous series of studies on prisoners</p><p>in Vermont that showed that, depending on what the researchers fed them, it</p><p>could take up to one hundred thousand more calories to create the same</p><p>amount of weight gain. So you’ll learn how they effectively made one</p><p>hundred thousand calories disappear. But I’m getting ahead of myself.</p><p>A DETECTIVE STORY IN FOUR PARTS</p><p>In part I, the book starts with an outline of our growing problem with</p><p>obesity—the causes, the consequences, and the solutions tried to date. It</p><p>answers questions such as: What led to the explosive increase in obesity</p><p>starting in the late 1970s? Is being overweight really as bad for your health</p><p>as “they” say? And what about the safety and efficacy of nonlifestyle</p><p>approaches, such as stomach stapling, diet drugs, and weight-loss</p><p>supplements?</p><p>Then, in my attempt to build the optimal weight-loss strategy from</p><p>scratch, I spend part II exploring all the key ingredients that might go into</p><p>creating the ideal recipe for losing body fat. In part III, we see how all the</p><p>diets out there stack up against this list of criteria, and we piece together the</p><p>foremost formula for healthy, sustainable weight control. You also get the</p><p>tools to be able to assess all the newer-than-new diets that haven’t even</p><p>come out yet.</p><p>After that come the boosters. In part IV, I unveil all the tricks and tweaks</p><p>for fast-tracking weight loss that I’ve found through my years of scouring</p><p>the medical literature. These are ways in which any diet can be modified to</p><p>maximize the dissolution of body fat. I arrange the boosters in a simple</p><p>daily checklist so you can pick and choose a portfolio of techniques that</p><p>works best for you. I have to warn against skipping to this section and going</p><p>for the quick fixes while continuing to eat the same crappy foods. Though</p><p>there are indeed different ways to eat the same foods to achieve better</p><p>results, the boosters are strictly meant to be adjuncts to a healthy diet.</p><p>In the final section, I lay to rest all the burning questions on burning fat:</p><p>What are the best ways to exercise to achieve maximum weight loss? How</p><p>can you safely boost your metabolism? What is the optimum amount of</p><p>sleep? What does the science say about ketogenic diets, intermittent fasting,</p><p>and high-intensity interval training? I also introduce you to specific foods</p><p>that double as fat blockers and fat burners, and starch blockers and appetite</p><p>suppressants. And did you know that the different timing, frequencies, and</p><p>combinations of foods can also matter? There’s even a food that can prevent</p><p>the metabolic slowing that your body uses to frustrate your weight-loss</p><p>attempts.</p><p>Skeptical? You should be! I was too.</p><p>I went into this thinking I would just end up railing against all the</p><p>gimmicky snake oil out there and put out much of the same standard advice</p><p>on trimming calories and hitting the gym. I imagined what would set this</p><p>work apart would be its comprehensiveness and strict grounding in science.</p><p>I figured this book would distinguish itself—but more as a book of</p><p>reference than revolution. I certainly never thought I’d stumble across some</p><p>novel weight-loss strategy. I just didn’t realize how many new paths would</p><p>be opened up by our newfound transformations in understanding of so</p><p>many fields of human physiology. It’s been thrilling to weave together all</p><p>these cutting-edge threads to design a weight-loss protocol based on the</p><p>best available evidence.</p><p>This has been a mammoth but joyful undertaking. People sometimes ask</p><p>me why I don’t go on vacations or even take a day off. I have to explain that</p><p>I feel as though my entire life is a holiday. I feel so blessed to be able to</p><p>dedicate my time to helping people while doing what I love: learning and</p><p>sharing. I can’t imagine doing anything else.</p><p>I. The Problem</p><p>THE CAUSES</p><p>The Weight of the World</p><p>Obesity isn’t new, but the obesity epidemic is. We went from a few</p><p>corpulent queens and kings, like Henry VIII and Louis VI (known as Louis</p><p>le Gros, or “Louis the Fat”),18 to a pandemic of obesity, now considered to</p><p>be perhaps the direst and most poorly contained public health threat of our</p><p>time.19 Today, 71 percent of American adults are overweight and 40 percent</p><p>of men and women appear to have so much body fat that they can be</p><p>classified as obese, and there’s no end in sight.20 Earlier reports had</p><p>suggested the rise in obesity was at least slowing down, but that doesn’t</p><p>actually appear to be the case.21 Similarly, we had thought we were turning</p><p>the corner on childhood obesity after thirty-five years of unrelenting bad</p><p>news, but the bad news marches on.22 Child and adolescent obesity rates</p><p>have continued to rise, now into the fourth decade.23</p><p>Over the last century, obesity appears to have jumped tenfold, from as</p><p>few as one in thirty people24 to now one in three, but it wasn’t a steady rise.</p><p>Something seems to have happened around the late 1970s, and not just in</p><p>the United States.25 The obesity pandemic took off at about the same time in</p><p>most high-income countries around the globe in the 1970s and 1980s. The</p><p>fact that the rapid rise appeared almost concurrently across the</p><p>industrialized world suggests a common cause.26</p><p>What might that trigger have been?</p><p>Any potential driver would have had to be global in nature and coincide</p><p>with the upswing of the epidemic, so the change would have had to have</p><p>started about forty years ago and been able to spread rapidly around the</p><p>world.27 So how do the various theories stack up? Some have blamed</p><p>changes in our “built environment,” for instance, pointing to shifts in city</p><p>planning that have made our communities less conducive to walking,</p><p>biking, and grocery shopping.28 But that doesn’t meet our criteria for a</p><p>credible cause because there was no universal, simultaneous change in</p><p>global neighborhoods within that time frame.29</p><p>If you do a survey of hundreds of policy-makers, most blame the obesity</p><p>epidemic on “lack of personal motivation,”30 but that makes little sense.</p><p>Here in the United States, for example, obesity shot up across the entire</p><p>population in the late 1970s. Are you telling me that every sector of the</p><p>U.S. population experienced some sort of simultaneous decline in</p><p>willpower?31 Each age, sex, and ethnic group, with all their different</p><p>attitudes and experiences, coincidentally lost their collective capacity for</p><p>self-control at the same time?</p><p>More plausible than a global change in the nature of our characters</p><p>would be some global change in the nature of our lives.32</p><p>Fast Food vs. Slow Motion</p><p>The food industry blames inactivity. “If all consumers exercised,” said the</p><p>CEO of PepsiCo, “obesity wouldn’t exist.”33 Coca-Cola went a step further</p><p>and spent $1.5 million to create the Global Energy Balance Network to</p><p>downplay the role of diet in the obesity epidemic. Leaked internal</p><p>documents show the company planned on using the front group to serve as</p><p>a “weapon” to “change the conversation” about obesity in its “war” with the</p><p>public health community.34</p><p>This tactic is so common among food and beverage companies it even</p><p>has a name: leanwashing. You’ve likely heard of greenwashing, where</p><p>companies deceptively pretend to be environmentally friendly.</p><p>Leanwashing is the term used to describe companies that try to position</p><p>themselves as helping to solve the obesity crisis when, instead, they’re</p><p>directly contributing to it.35 For example, Nestlé, the largest food company</p><p>in the world, has rebranded itself the “world’s leading nutrition, health and</p><p>wellness company.”36 Yes, that Nestlé, of Nestlé Nesquik fame, makers of</p><p>Cookie Crisp cereal and more than one hundred different brands of candy,</p><p>including Butterfinger,</p><p>annual weight gain and those on the most inflammatory</p><p>diets have a 32 percent greater risk of becoming overweight or obese during</p><p>about an eight-year period.969 The researchers were able to control for such</p><p>nondietary factors as smoking and exercise—but is it possible that higher</p><p>Dietary Inflammatory Index scores are just a reflection of a poor diet in</p><p>general? The concept that diets with fewer fruits and vegetables and more</p><p>meat and junk might lead to more weight gain isn’t exactly revelatory. How</p><p>do we know the connection has anything at all to do with inflammation?</p><p>Dozens of studies have shown that obesity is strongly associated with</p><p>increased levels in the blood of inflammatory markers like C-reactive</p><p>protein,970 but is that inflammation a cause or a consequence of obesity?</p><p>We used to think fatty tissue was just a passive depot for the storage of</p><p>excess fat,971 but we now know it actively secretes inflammatory chemicals.</p><p>Fatty tissue can expand so quickly it may outpace its blood supply and</p><p>become starved of oxygen.972 (You can insert an electrode directly into an</p><p>obese belly and measure how low the oxygen levels fall compared with</p><p>healthy-weight individuals.973) This is thought to contribute to fat cell death,</p><p>which draws out inflammatory cells like macrophages, a type of roaming</p><p>white blood cell present in pus, to try to clean up the mess. If you take a</p><p>belly biopsy of an obese individual, you can see that the fat is swarming</p><p>with macrophages.974 The macrophages then appear to get stuck and fuse</p><p>into giant cells, a hallmark of chronic inflammation seen in resistant</p><p>infections like tuberculosis or around foreign bodies the body can’t clear.975</p><p>All the while, inflammatory compounds spill out into general circulation.976</p><p>Obesity, then, appears to lead to systemic inflammation, rather than the</p><p>other way around.977,978 And even if inflammation had no role in the cause</p><p>of obesity, you’d still want any weight-loss diet to be anti-inflammatory to</p><p>mediate the inflammatory consequences of the excess body fat. But there is</p><p>a way inflammation seems to play a cause-and-effect role in the obesity</p><p>epidemic: inflammation in our brains. To understand how inflammation in</p><p>the brain can lead to obesity, we must first understand how our brains</p><p>regulate our appetites.</p><p>Obesity is widely viewed as a neuroendocrine (nerve and hormone)</p><p>disorder caused by damage to the appetite-regulating circuits in our</p><p>brains.979 Wait—isn’t it caused by indulgence in the cheap and easy</p><p>overabundance of aggressively marketed fatty, sugary, high-calorie foods?</p><p>Well, if that’s all it was, wouldn’t even more people be overweight? Maybe</p><p>90 percent instead of just 72 percent?980 The question that perhaps most</p><p>intrigues obesity researchers is not Why are so many people fat? but rather,</p><p>given how obesity-inducing our food system is, Why isn’t everyone fat?981</p><p>I know this is going to sound odd in a book about the obesity epidemic,</p><p>but our bodies are actually remarkably good at regulating our weight. Think</p><p>about it. We eat about a million calories a year, yet most of us only fluctuate</p><p>by a few pounds. Without even thinking about it, our bodies maintain our</p><p>energy balance with a precision exceeding 99.5 percent.982 You couldn’t</p><p>even count calories that effectively. Literally. When put to the test, the</p><p>calorie labeling on packaged foods was sometimes found to be so</p><p>inaccurate that one investigation discovered up to a quarter of foods</p><p>sampled failed to even comply with the 20 percent error allowed by the</p><p>FDA.983 How do our bodies do better?</p><p>The master regulator of metabolism is the hypothalamus,984 an almond-</p><p>sized part of our brains near eye level in the middle of our skulls. Just like</p><p>your hypothalamus regulates body temperature by causing you to shiver</p><p>when you get too cold and sweat when you get too hot, it also regulates</p><p>body fat, causing you to eat more when you get too thin and less when you</p><p>get too fat. It’s our “satiety center,” carefully controlling our appetites so we</p><p>eat just the right amount over time and don’t gain or lose too much weight.</p><p>But how exactly does the hypothalamus know how fat we are?</p><p>Our fat cells release a hormone called leptin, from the Greek leptos for</p><p>thin. The more fat we have on our bodies, the higher the levels of leptin in</p><p>our blood. The hypothalamus uses leptin levels as our fat thermostat and</p><p>downregulates our appetites when leptin levels get too high.</p><p>“Experimental Obesity in Man,” a classic set of prisoner experiments</p><p>published in the 1970s, showed how difficult it was to perturb this system</p><p>of appetite regulation when it is working properly. Lean inmates in a</p><p>Vermont prison were fed up to ten thousand calories a day in closely</p><p>supervised meals with a goal of increasing their weights by up to 25</p><p>percent.985 This turned out to be surprisingly difficult. Most started dreading</p><p>breakfast and sometimes involuntarily threw it up.986 Most powered</p><p>through, though, and achieved the excess weight target. But as soon as they</p><p>were released from the experiment, they tended to rapidly shed all those</p><p>extra pounds and get back to around their original weights.987</p><p>This all makes sense based on what we now know about the leptin-</p><p>hypothalamus fat thermostat. All that extra body fat led to extra leptin</p><p>production, and in response, their hypothalami profoundly depressed their</p><p>appetites until they got back down to baseline. When their fat volumes</p><p>dropped back to normal, their leptin levels presumably dropped back to</p><p>normal, too, and so it seems their hypothalami made their normal appetites</p><p>return. How, then, do people become obese—and what does it have to do</p><p>with inflammation?</p><p>Inflammatory Brain Damage as a Cause of Obesity</p><p>People can gain weight—and keep it on—when there is damage to this</p><p>leptin-hypothalamus circuit. Extreme cases of so-called hypothalamic</p><p>obesity date back to 1840, when an “uncommonly obese” woman was</p><p>found on autopsy to have a tumor near her hypothalamus.988 Anything that</p><p>harms the hypothalamus can cause obesity—head trauma, aneurysms, brain</p><p>surgery.989 Once the damage occurs and that feedback loop is broken, the</p><p>hypothalamus can no longer respond adequately to rising leptin warning</p><p>signals. As a result, people can develop out-of-control appetites, even to the</p><p>point of having to be locked up for stealing food.990</p><p>You can imagine how the same thing could happen if a baby were born</p><p>with congenital leptin deficiency, a condition in which their fat cells</p><p>couldn’t produce leptin at all. Their hypothalami would never get the too-</p><p>much-fat signal to turn down their appetites—and indeed, such children eat</p><p>constantly, tragically becoming so obese some can hardly walk, sometimes</p><p>exceeding one hundred pounds by age four.991</p><p>But inject these children with leptin, and the weight comes off. The first</p><p>child this was tried on was a nine-year-old girl weighing more than two</p><p>hundred pounds. Within days of the leptin administration, there was a</p><p>marked change in her eating behavior. For the first time in her life, she felt</p><p>satiated eating the same quantity of food as her siblings, in effect proving</p><p>the importance of leptin in appetite regulation.992</p><p>Want to guess how eager the drug industry was to start injecting people</p><p>with leptin as the next new miracle weight-loss cure? But remember: Obese</p><p>individuals are already awash with excess leptin secreted by all their extra</p><p>fat. The problem is that the leptin just isn’t working.</p><p>An analogy can be made with diabetes. In type 1 diabetes, blood sugars</p><p>get too high because people can’t make enough insulin. Inject them with</p><p>insulin, and their blood sugars come right back down. That’s like the kids</p><p>with the rare leptin birth defect: Their body weights get too high because</p><p>they can’t make enough leptin, but if you inject them with leptin, their body</p><p>weights come right back down. In contrast, type 2 diabetics can make</p><p>enough insulin, but the target tissues are resistant to the effects of the</p><p>insulin. There’s already enough insulin in the body—in fact, there’s often</p><p>excess insulin, as the pancreas tries to pump out more to overcome the</p><p>resistance. The body just isn’t responding properly.</p><p>Similarly, obesity is thought to be caused by leptin resistance.</p><p>Overweight individuals produce enough leptin—excess leptin, actually—</p><p>but the target tissue, the hypothalamus, is resistant to its effects. So what</p><p>can we do about it? Well, what do we do to treat insulin resistance?</p><p>Broadly, there are two ways to approach type 2 diabetes: The traditional</p><p>medical model tries to overwhelm the system by injecting even more</p><p>insulin, whereas the lifestyle medicine model instead treats the cause,</p><p>attempting to reverse the insulin resistance itself so the body’s own natural</p><p>feedback loop can start working again. Similarly with obesity, attempts</p><p>have been made to try to overwhelm the system by injecting even more</p><p>leptin, but why not instead treat the underlying problem by reversing the</p><p>leptin resistance?993</p><p>Interestingly, insulin resistance and leptin resistance may share a</p><p>common cause: lipotoxicity, from the Greek lipos, meaning animal fat.</p><p>Lipotoxicity is caused by eating a diet high in calories with too much</p><p>saturated fat and can result in inflammation.994</p><p>Out of the Frying Pan and Into the Fire</p><p>If you feed lab animals saturated fat, the fat crosses the blood-brain barrier</p><p>and accumulates in the hypothalamus within hours, causing inflammation,</p><p>leptin resistance, and overeating.995 You can re-create this scenario right in a</p><p>petri dish. If you drip the main saturated fat from the American diet (found</p><p>mostly in meat and dairy)996 onto hypothalamic neurons, inflammation can</p><p>be turned on like a light switch.997 The original animal studies were done</p><p>with lard-based diets, but butterfat seems to work just as well.998 The good</p><p>news is that when the lab animals were switched back to eating their regular</p><p>low-fat food, their hypothalamic inflammation disappeared.999</p><p>So what about in humans? Extrapolating data from lab animals is</p><p>infamously fraught with difficulty,1000 and obesity research is no</p><p>exception.1001 For one, the diets between lab animals and humans are</p><p>incomparable. Lard-based, high-fat rodent food may be around 60 percent</p><p>fat.1002 But bacon is only about 40 percent lard,1003 so you could eat a 100</p><p>percent bacon diet and still not get the kind of fat intake that the rodent was</p><p>receiving.</p><p>Because of the difficulty of extrapolating from animals, we didn’t know</p><p>if the same kind of hypothalamic inflammation occurred in obese humans</p><p>until researchers were able to use high-resolution MRI brain scans to put it</p><p>to the test.1004 Subsequent comparisons with brain slices obtained on</p><p>autopsy confirmed that what researchers were seeing on the MRIs was</p><p>indeed the same hallmarks of hypothalamic inflammation.1005 The nerves</p><p>were inflamed, but not destroyed, suggesting the whole process could be</p><p>reversible. (No improvement in hypothalamic inflammation was seen about</p><p>ten months after bariatric surgery,1006 but this is perhaps because stomach</p><p>stapling can force a change in diet quantity but not necessarily diet quality.)</p><p>Randomized crossover trials show that by covertly increasing saturated</p><p>fat intake, you can reversibly induce negative changes in brain function,</p><p>mood, inflammation, and resting metabolic rate, and even, apparently,</p><p>undercut motivation to exercise.1007,1008 Study subjects become 12–15</p><p>percent less physically active on high–saturated fat diets compared to low–</p><p>saturated fat diets.1009 And note that researchers used a saturated plant fat—</p><p>palm oil—found in some nondairy cheeses, vegan spreads, and other</p><p>processed junk, so an anti-inflammatory diet is not just a move toward a</p><p>more plant-based diet in general but specifically one centered around</p><p>whole, unprocessed plant foods.</p><p>If Memory Serves</p><p>The hippocampus is the seat of memory in the brain. Structurally, it’s composed of two</p><p>upside-down, seahorse-shaped ridges nestled deep in the temporal lobes. In Alzheimer’s, it’s</p><p>one of the first areas to be hit. If saturated fat–induced inflammatory damage to the metabolic</p><p>center of the brain may be contributing to obesity, what might that same damage be doing to</p><p>the memory center?</p><p>When lab animals are fed saturated fat (lard), neurons in their hippocampi exhibit stress</p><p>within seventy-two hours.1010 Subsequent memory problems and obesity suggest a vicious</p><p>cycle, where saturated fat harms the hippocampus, causing memory impairments that result in</p><p>even more lard being eaten—it’s as if they had forgotten how much they’d already had—and</p><p>then goes on to cause more brain damage, cognitive dysfunction, and weight gain.1011 This</p><p>finding inspired human investigations. MRI imaging scans taken of people’s brains</p><p>approximately four years apart found that those eating junky, meat-centered diets experience a</p><p>significant shrinkage of their hippocampi compared to those eating more healthful diets.1012</p><p>Saturated fat consumption is also associated with accelerated cognitive decline, but you don’t</p><p>know if any of this is cause and effect until you put it to the test.1013</p><p>Researchers put people on a high-fat, ketogenic diet and confirmed a blunting of cognition,</p><p>including impaired reaction times and attention, within seven days.1014 Another research team</p><p>found that a high-fat diet impaired brain function in just five days: “Deficits were found in the</p><p>speed of retrieval of information from memory, the ability to intensely focus attention, and</p><p>performance of a complex higher order task involving working memory and attention.”1015</p><p>Even one bad meal a day for four days can impair our brain function. Australian</p><p>researchers randomized men and women to eat either a breakfast high in saturated fat and</p><p>added sugars or a healthier breakfast for four consecutive days. That’s all it took to cause a</p><p>significant loss in hippocampus-dependent learning and memory. People were instructed to</p><p>repeat a list of twelve words over and over, for example, and then try to recall them twenty</p><p>minutes later. Most were able to remember about 90 percent of them. For those randomized to</p><p>eat one fatty meal a day for four days, their recall dropped down to around 75 percent.</p><p>Although the high-fat breakfasts also had added sugar, overall sugar intake didn’t change over</p><p>the four days or differ from the control group, but their intake of saturated fat was double.1016</p><p>The fatty breakfast group also appeared to suffer a hit to their interoception, the ability to</p><p>perceive internal body states. In other words, they had to eat more food, about seventy</p><p>calories’ worth, to feel the same sensation of satiety and fullness. The impaired hunger</p><p>sensitivity, combined with the poorer memory retention, would seem to be a setup for weight</p><p>gain. The hippocampal injury should be reversible, though. The researchers suggest that the</p><p>recovery period to repair the damage done by those four fatty meals may be as short as four to</p><p>six weeks.1017</p><p>Even though overall sugar intake didn’t change, the researchers suspect the breakfast</p><p>“burst” of saturated fat and added sugar was the most plausible cause.1018 A single meal high</p><p>in saturated fat (equivalent to a quarter-pound cheeseburger and large fries) has been shown to</p><p>increase whole-body insulin resistance by 25 percent.1019 That, combined with the added</p><p>sugars, could spike blood sugars high enough to contribute to the hippocampal dysfunction.</p><p>As the accompanying medical journal editorial put it, a single load of saturated fat “packs a</p><p>punch.”1020</p><p>FOOD FOR THOUGHT</p><p>By choosing to eat more anti-inflammatory foods and fewer pro-inflammatory foods, we</p><p>may be able to both prevent and treat the damage to the appetite-regulating apparatus in our</p><p>brains that can lead to—and sustain—obesity.</p><p>In the Dietary Inflammatory Index, the single most anti-inflammatory food is the spice</p><p>turmeric, followed by ginger and garlic, and the most anti-inflammatory beverage is green or</p><p>black tea. The two most anti-inflammatory food components are fiber and flavones.1021</p><p>Dietary fiber is found in all whole plant foods, but it is</p><p>most concentrated in legumes, such as</p><p>beans, split peas, chickpeas, and lentils.1022 Flavones are plant compounds concentrated in</p><p>herbs, vegetables, and fruits,1023 and the leading sources in the U.S. diet are parsley, bell</p><p>peppers, celery, apples, and oranges.1024 The most flavone-filled beverage is chamomile</p><p>tea.1025</p><p>The most pro-inflammatory food components are saturated fat and trans fat. Essentially,</p><p>the top five sources of saturated fat in the United States are cheese, desserts like cake and ice</p><p>cream, chicken, pork, and then burgers.1026 Thankfully, with the ban on added trans fat, the</p><p>only remaining sources in the food supply will be the small amounts found naturally in meat</p><p>and dairy and created in the refining of vegetable oils.1027</p><p>Ultimately, an anti-inflammatory diet in clinical practice first and foremost “focuses on</p><p>eating whole, plant-based foods.”1028 As I mentioned, not all plant-derived foods are anti-</p><p>inflammatory (like the tropical oils), just as not all animal foods are pro-inflammatory.</p><p>Omega-3 fatty acids found in fish, for example, score as an anti-inflammatory component in</p><p>the Dietary Inflammatory Index.1029 Though fish oil may not affect systemic inflammation in</p><p>healthy individuals,1030 it can reduce inflammatory markers in those with chronic</p><p>disease.1031 Curiously, unlike plant-based omega-3 sources like nuts, fish consumption is not</p><p>associated with lower inflammatory disease mortality.1032 Perhaps the benefits of the omega-</p><p>3s are offset by the industrial toxins that now contaminate much of the aquatic food</p><p>chain.1033</p><p>CLEAN</p><p>Obesogenic Pollutants</p><p>The notion that we are being exposed to obesogenic pollutants—that is,</p><p>obesity-generating chemicals—went from mere speculation in an</p><p>alternative medicine journal in 20021034 to strong scientific plausibility</p><p>within a decade.1035 The supposition started out on pretty shaky ground,</p><p>pointing out, for instance, that recent national surveys appear to show our</p><p>weight exceeds what we report eating.1036 Therefore, the argument went,</p><p>something else must be going on beyond just calories in and calories out.</p><p>But it is notoriously difficult to get an accurate calorie count from dietary</p><p>recall surveys, especially from overweight individuals, who tend to</p><p>underreport their intakes.1037</p><p>Theoretically, though, the obesogen concept was not that much of a</p><p>stretch. All sorts of synthetic chemicals cause obesity in humans: They’re</p><p>called medications. Multiple classes of drugs are infamous for contributing</p><p>to weight gain, such as certain types of antidepressants, antipsychotics, and</p><p>diabetes medications.1038 The animal agriculture industry has made fattening</p><p>into a science, utilizing a whole array of chemicals, hormones, and</p><p>pharmaceuticals to pack on the pounds.1039 An analysis of chicken feathers</p><p>found that the poultry industry appears to feed the birds everything from</p><p>arsenic1040 to Prozac.1041 (Poultry producers say feeding caffeine “keeps the</p><p>chickens awake so that they eat more and grow faster.”1042)</p><p>So what evidence do we have that chemicals are making us grow fatter</p><p>too?</p><p>Early on, the purported link between chemical pollutants and obesity</p><p>was based in part on the observation that the rise in chemical production</p><p>seemed to coincide with the rise of the obesity epidemic.1043 Yes, but how</p><p>many other millions of changes have there been over the last half century?</p><p>Why jump to pollution when there are so many other easier explanations,</p><p>everything from couch potatoes to fried potatoes?</p><p>One clue that pollutants may be playing some role is that our pets are</p><p>also getting fatter.1044</p><p>Fido isn’t drinking more soda. Of course, the more Seinfeld reruns we</p><p>watch, the less we may walk the dog, but what about our cats? Are we just</p><p>giving them—and our kids—a few too many treats? That would seem a</p><p>simpler explanation than imagining pervasive, obesity-causing chemicals</p><p>building up in the pet and person food chains. It’s not just our kitties and</p><p>kiddies, though. A remarkable paper was published in 2011 entitled</p><p>“Canaries in the Coal Mine: A Cross-Species Analysis of the Plurality of</p><p>Obesity Epidemics.”1045 It was a study of more than twenty thousand</p><p>animals from twenty-four distinct populations, including feral animals, lab</p><p>animals, and even urban and rural rats. The researchers found “large and</p><p>sustained” increases in body weight nearly across the board, not just among</p><p>pampered pets.</p><p>We’re all getting fatter. The odds that every single population studied</p><p>would be getting heavier just by chance are around eight million to one.</p><p>Given that evidence, it’s hard to blame our collective weight problem just</p><p>on things like dwindling phys ed classes, the advent of video games, or</p><p>junkier food. And our infants are heavier too. There’s been an alarming rise</p><p>in obesity rates among young children under two years of age.1046 It’s hard</p><p>to argue that today’s six-month-olds are eating more or exercising less than</p><p>they were in previous generations.</p><p>These are the kinds of data that piqued serious interest into the search for</p><p>obesogenic chemicals, and to date, about twenty different purported</p><p>obesogens have been found.1047 The most well-studied thus far is a group of</p><p>tin-based biocides known as organotins.1048</p><p>The Case of the Sex-Change Paint</p><p>Organotins were used in “antifouling” paint applied to the outer hulls of</p><p>ships and other submerged structures like fish farm cages and oil rigs to</p><p>prevent barnacles from attaching. But once this chemical was being used</p><p>widely, scientists began to notice that female sea snails started to grow</p><p>penises.1049 As a result of a variety of hormone-disrupting effects,</p><p>organotins were banned from the maritime industry in 2008.1050 Disrupting</p><p>hormones isn’t the only thing these compounds do, though. Organotins also</p><p>activate peroxisome proliferator-activated receptor gamma, or PPAR-γ,</p><p>which is the master regulator of adipogenesis, the process of creating new</p><p>fat cells (known as adipocytes).1051</p><p>Once activated, PPAR-γ recruits connective tissue stem cells to turn into</p><p>new fat cells. PPAR-γ stimulation can also cause fat cells to swell up even</p><p>larger with fat. In other words, contact with this chemical leads to more, and</p><p>bigger, fat cells,1052 and exposure in the womb to organotins may</p><p>permanently establish an elevated fat cell count throughout our lives.1053</p><p>By the time we hit early adulthood, the total number of fat cells in our</p><p>bodies remains fairly stable.1054 When we gain or lose weight, we are pretty</p><p>much just enlarging or shrinking our existing fat cells. Starting out with a</p><p>higher number of fat cells or gaining more later in life may make it easier to</p><p>put on pounds, harder to lose them, and more difficult to maintain weight</p><p>loss.1055</p><p>What’s more, each fat cell we make may be at the expense of one fewer</p><p>bone, cartilage, or muscle cell.1056 The connective tissue stem cells recruited</p><p>by PPAR-γ to become fat cells could have otherwise become any of those</p><p>other types of cells, so excess PPAR-γ activation could potentially set us up</p><p>not only for obesity but also osteoporosis.1057 The swiss cheese–like holes in</p><p>osteoporotic bone are often filled with fat.1058 Perhaps this is why the PPAR-</p><p>γ-activating diabetes drug rosiglitazone (sold as Avandia) not only causes</p><p>weight gain as a side effect but appears to increase the risk of bone fractures</p><p>as well.1059</p><p>How are we exposed to PPAR-γ-activating organotin compounds?</p><p>Mainly through food, especially from fish and other seafood.1060 Even</p><p>though organotins were banned on boats and other marine vessels years</p><p>ago, they persist in our waterways, and contamination levels in fish fillets</p><p>remain comparable to those obtained worldwide before the ban.1061 Some</p><p>fish are worse than others. Halibut, swordfish, and canned tuna have been</p><p>recorded as having the highest levels,1062 and a sampling of U.S. market-</p><p>bought seafood found that farm-raised fish was generally worse than wild-</p><p>caught.1063</p><p>Are the contamination levels high enough to be of concern? Researchers</p><p>calculated the “tolerable average</p><p>residue levels” for tributyltin, a common</p><p>organotin, in seafood products around the world, defined as the levels in</p><p>seafood tolerable for the average adult consumption pattern. Of the eighty-</p><p>four U.S. seafood samples examined, seven products exceeded this level, or</p><p>about 8 percent.1064 Note this is for the average adult consumer, so the</p><p>percentage would be higher in children or those who ate more seafood than</p><p>average. The percentage violating the tolerable average dose exceeds 30</p><p>percent in Japan, for example, but that is because the Japanese tend to eat</p><p>more seafood, not because their fish is any more contaminated.</p><p>Everybody’s Plastic</p><p>Persistent pollutants have blanketed the world and now are found even in</p><p>the Arctic, thousands of miles from known sources. Fortunately, many have</p><p>been regulated strictly since the Stockholm Convention in 2004,1065 but</p><p>unfortunately, there continue to be hormone-disrupting chemicals that are</p><p>underregulated or not regulated at all. DDT, the banned pesticide now found</p><p>mostly in meat, particularly fish,1066 is a “presumed” human obesogen1067</p><p>responsible for perhaps thousands of annual childhood obesity</p><p>cases.1068,1069,1070 Meanwhile, the number attributable to the plastics chemical</p><p>bisphenol A (BPA) may be in the tens of thousands.1071</p><p>BPA was first developed more than a century ago as a synthetic</p><p>estrogen.1072 It wasn’t until the 1950s, however, that the manufacturing</p><p>industry realized BPA could also be used to make polycarbonate plastic.</p><p>Despite having long been recognized as having hormonal effects,1073 BPA</p><p>rapidly became one of the most widely used chemicals worldwide.1074 It’s</p><p>currently one of the highest-volume chemicals produced globally, with</p><p>more than six billion pounds made each year.1075</p><p>In a petri dish, BPA was shown to accelerate the formation of new fat</p><p>cells1076 and increase fat accumulation within fat cells, but that was at doses</p><p>many thousands of times the concentration found in most people’s</p><p>bloodstreams.1077 Though more than 90 percent of Americans tested in a</p><p>national survey had BPA circulating in their bodies,1078 it was at</p><p>concentrations down around 10 nM.1079 In contrast, those early studies were</p><p>using 25,000–80,000 nM. We knew there were estrogenic effects even at</p><p>those low, real-world doses,1080 but it wasn’t discovered until recently—in</p><p>part using fat samples taken from children1081 and adults1082 undergoing</p><p>abdominal surgery—that fat cell formation could also be affected by BPA at</p><p>as little as 1 nM.1083 Even once metabolized by the liver, which destroys the</p><p>estrogenic effects, BPA retains the ability to promote adipogenesis, the</p><p>process of creating fat cells.1084,1085</p><p>BPA exposure at all life stages tends to correlate with increased</p><p>weight,1086 and population studies in the United States, Canada, China, and</p><p>South Korea have found it to be associated with various body fat</p><p>measures.1087 Six out of seven BPA studies on general obesity and five out</p><p>of five studies on abdominal obesity have found a link. Putting together all</p><p>the studies, those with the highest BPA levels had 67 percent greater odds</p><p>of obesity compared to those with the lowest.1088 In men, BPA may also be</p><p>associated with lower lean body mass.1089 Those in the highest quarter of</p><p>BPA urine levels averaged about three pounds less lean mass than those in</p><p>the lowest quarter, suggesting BPA may have negative effects on muscle as</p><p>well. (BPA exposure is also associated with declining male sexual function,</p><p>but that’s a whole other book.1090)</p><p>How can we stay away from BPA? A small amount of exposure comes</p><p>from handling thermal paper, such as cash register receipts and printed</p><p>tickets,1091 especially if our hands are greasy or wet after the application of</p><p>lotion or sanitizer.1092 Ninety percent of exposure, however, appears to be</p><p>from our diets.1093 How can you tell? When people fast for a couple of days,</p><p>their BPA levels drop as much as tenfold.1094</p><p>Fasting isn’t very sustainable, though. Researchers had families try a</p><p>“fresh foods intervention,” where the families switched away from canned</p><p>and processed foods. (Why canned? BPA is used in the epoxy that lines</p><p>most canned goods, since it costs companies about 2 cents more per can to</p><p>use non-BPA material instead.1095) Simply by avoiding canned and</p><p>processed foods, the highest BPA levels dropped 76 percent within three</p><p>days.1096</p><p>Alternately, you can conduct the experiment by adding a serving of</p><p>canned soup to people’s daily diets. Compared to serving soup prepared</p><p>with fresh ingredients, five days of a daily serving of canned soup led to a</p><p>1,000 percent rise in BPA levels in the urine.1097 It could have been even</p><p>worse had they used cans of condensed soup, which may have about 85</p><p>percent more BPA than cans of ready-to-serve soup. Otherwise, the highest</p><p>BPA levels have been found in canned green beans and canned tuna.1098 The</p><p>only fresh food found contaminated with BPA in the United States was</p><p>sliced turkey.1099</p><p>Take-Home Tip: BPA is why I specify in The How Not to Die Cookbook to choose beans and</p><p>tomato products in jars, aseptic packaging (Tetra Paks), or BPA-free cans. Eden Foods, for</p><p>example, has a line of BPA-free canned beans. You can also BYOB: Boil Your Own Beans.</p><p>It’s cheaper, and they end up with a better texture. My favorite way is to use an electric</p><p>pressure cooker (like an Instant Pot).</p><p>Phthalates are another class of plastics compounds associated with</p><p>weight gain.1100 A European consensus panel of obesogen experts gave a</p><p>40–69 percent probability of phthalate exposure causing more than fifty</p><p>thousand cases of obesity annually in older women.1101 Rapid plunges in</p><p>phthalate levels upon fasting implicated dietary sources,1102 and significant</p><p>drops within days of having people eat a vegetarian diet gave researchers a</p><p>clue as to where to look.1103</p><p>Indeed, high concentrations of phthalates have been found consistently</p><p>in some meats (particularly poultry), fats, and some dairy products.1104 The</p><p>fact that egg consumption is also associated with elevated phthalate levels</p><p>suggests that the chickens themselves are contaminated even before they’re</p><p>wrapped in plastic for sale.1105 The phthalates in dairy, though, appear to be</p><p>from the plastic tubing in milking machines, as dairy from hand-milked</p><p>cows can have ten times less.1106 Diets high in meat and dairy can</p><p>sometimes contain up to four times the Environmental Protection Agency’s</p><p>recommended daily phthalate safety limit.1107</p><p>This is what makes population studies linking pollutants and obesity so</p><p>difficult.1108 Phthalate levels just may be an indicator of fried chicken intake,</p><p>and BPA levels a sign of SPAM consumption. Similarly, just as exposure to</p><p>plastics chemicals may be an indicator of a diet bereft of fresh foods, DDT</p><p>exposure may be a marker for the foods that frequently contain the highest</p><p>levels of DDTs identified by the Endocrine Society: “meat, fish, poultry,</p><p>eggs, cheese, butter and milk.”1109 Pollutants like DDT are just one of many</p><p>reasons why diets rich in those foods might be associated with obesity risk.</p><p>Take-Home Tip: BPA and phthalate metabolites are detectable in 95 percent of the U.S. adult</p><p>population.1110 BPA is already banned from baby bottles and sippy cups in the United</p><p>States,1111 but for other plastic containers, keep an eye out for recycle codes 3 and 7, as those</p><p>indicate items that are more likely to contain high levels of BPA.1112 Certain phthalate levels</p><p>are now banned from toys for children,1113 but not from “toys” for adults. Jelly-based sex</p><p>toys are often made from a plasticized vinyl material packed with phthalates. Sticking to</p><p>water-based lubricants may reduce phthalate transfer a hundredfold, but such adult toys may</p><p>still have opposite the intended effect.1114 Women with the highest levels of phthalates</p><p>flowing through their bodies report more than twice the odds of lack of interest in sexual</p><p>activity.1115</p><p>Up in Smoke</p><p>In 2015, when meat was officially classified as a “known carcinogen” or a</p><p>“probable carcinogen” depending on</p><p>whether or not it was processed, the</p><p>focus was on substances generated during cooking, curing, or smoking,</p><p>rather than on pollutant contamination.1116 Given this, we could just follow</p><p>recommendations to keep cooking temperatures under 260°F, thereby</p><p>avoiding broiling, roasting, pan-frying, or any other cooking method that</p><p>causes a crust to form, and instead stick to boiling or microwaving to keep</p><p>the outside “pale and soft.”1117 But even just being around a barbecue may</p><p>be hazardous, based on the recognition that light clothing probably provides</p><p>little protection from gaseous carcinogens.1118</p><p>Polycyclic aromatic hydrocarbons (PAHs), a class of combustion by-</p><p>products found in cigarettes, car exhaust, and grilled meat,1119 may explain</p><p>why the Long Island Breast Cancer Study Project found a 47 percent</p><p>increase in breast cancer risk among postmenopausal women with a high</p><p>lifetime intake of grilled, barbecued, or smoked meats.1120 These</p><p>contaminants may be more than just carcinogenic—they may be obesogenic</p><p>as well. A nationwide study of thousands of young people found that the</p><p>more children are exposed to PAHs, the fatter they tend to be. And prenatal</p><p>exposure to these chemicals may cause a higher subsequent risk of</p><p>childhood obesity.1121</p><p>If you look at one of the most common of these toxins, smokers get</p><p>about half their exposure from food and half from cigarettes. For</p><p>nonsmokers, however, 99 percent may come from diet. The highest levels</p><p>are found in meat, with pork apparently worse than beef.1122 Even dark</p><p>green leafy vegetables like kale can get contaminated by pollutants in the</p><p>air, so don’t forage your dandelion greens next to the highway, and make</p><p>sure to rinse your broad-leafed greens well under running water.1123</p><p>PAHs are fat-soluble, so absorption may be diminished with eating</p><p>lower-fat foods,1124 but importantly, they don’t appear to build up in your</p><p>body. Unlike persistent pollutants like PCBs, a particularly toxic class of</p><p>man-made chemicals that may take fifty to seventy-five years to clear from</p><p>the body after regular (even monthly) meals of farmed Atlantic salmon,1125</p><p>PAHs can pass in and out of you in a day. If you have people eat a meal of</p><p>barbecued chicken, you can see a big spike in these chemicals in their</p><p>systems—up to a hundredfold increase—but the body can detoxify most of</p><p>them away within about twenty hours.1126 Rather than detoxing, though,</p><p>perhaps it would be better not to “tox” in the first place—at least not on a</p><p>daily basis.</p><p>Prepackaged Pollutants</p><p>Industrial chemical contaminants come prepackaged regardless of cooking</p><p>method in “diary [sic] products, meat and fish.”1127 (Although dioxins are</p><p>created when paper pulp is bleached, I have a feeling “diary” was an</p><p>autocorrect error.) The Food and Drug Administration has regulations about</p><p>toxic chemicals in the food supply, determining the “action levels” of</p><p>contaminants above which foods must be removed from the market, but</p><p>those levels tend to be far higher than the levels based on health standards</p><p>set by the Centers for Disease Control and Prevention (CDC). For example,</p><p>a glass of milk tainted with the amount of DDT permitted by FDA’s action</p><p>level would expose a consumer to nearly ten times the daily exposure</p><p>considered “safe” by the CDC, and a single serving of fish could be sold</p><p>with fifty times the daily limit.1128 Presumably, the reason the commercial</p><p>standards are so lax is because too much food would have to be pulled from</p><p>the shelves.</p><p>The USDA determined that, based solely on dioxin levels, American</p><p>children consuming average servings of meat, including poultry (which</p><p>regularly contained the highest levels they found), could be ingesting in</p><p>excess of the daily safety limit.1129 Taking all thirty-three chemical</p><p>pollutants in meat shown to be potentially carcinogenic into account, some</p><p>European toxicologists suggest limiting children’s consumption of beef,</p><p>pork, and chicken to no more than five servings a month, an average of no</p><p>more than one serving every six days or so.1130 In Europe, lamb is the most</p><p>contaminated and the recommendation calls for adults to eat no more than a</p><p>single serving every four or five months.1131</p><p>In the United States, if there was any standout, it would be chicken and</p><p>PBDE flame-retardant chemicals—not only compared to other meats but</p><p>also to other countries. U.S. chickens are about ten to twenty times more</p><p>contaminated than chickens tested from other countries.1132 Sadly, the newer</p><p>flame-retardant chemicals introduced to replace the original PBDEs also1133</p><p>activate adipogenesis, diverting stem cell development away from bone</p><p>building and toward the formation of fat.1134</p><p>Meat is certainly not the only source of flame-retardant exposure,</p><p>though, as those eating vegetarian diets only have about 25 percent lower</p><p>levels in their bloodstreams.1135 For other chemicals, meat may play a larger</p><p>role. Studies dating back over thirty years looking at the pollutants in the</p><p>breast milk of vegetarians have found the average vegetarian levels of some</p><p>pollutants were only 1–2 percent as high as the national average.1136 For six</p><p>out of seven pollutants reviewed, there wasn’t even an overlap in the range</p><p>of scores; the highest vegetarian value was lower than the lowest value</p><p>obtained in the general population. This is presumed to be because these</p><p>pollutants concentrate up the food chain, so by eating more from all the way</p><p>down the food chain, those eating more plant foods may have an edge.1137</p><p>The problem with studies just comparing populations is that you can’t</p><p>single out the diet. Maybe vegetarians have other lifestyle behaviors that</p><p>protect them. You don’t know until you put it to the test by changing</p><p>people’s diets and seeing what happens. That’s hard to do with persistent</p><p>pollutants like PCBs, which may take literally decades to detoxify from the</p><p>body, but we can get rid of heavy metals like mercury in a matter of</p><p>months. And, indeed, within three months of the exclusion of eggs and</p><p>meat, including poultry and fish, from people’s diets, there was a significant</p><p>drop in their levels of mercury, cadmium, and lead. Within just a few</p><p>months of changing their diets, the levels of toxic heavy metals in their</p><p>bodies dropped by up to about 30 percent.1138</p><p>What About Organic Meat?</p><p>What if we just stick to organic meat? Certified organic meat comes from</p><p>livestock fed organically produced feed free of pesticides and animal by-</p><p>products. Therefore, you would assume there would be less chemical</p><p>residue accumulation, but there hadn’t been any studies measuring the</p><p>chemical contamination in organic meat until recently. Researchers</p><p>acquired seventy-six samples of different kinds of meat, both organic and</p><p>conventional, and quantified their levels of contamination with thirty-three</p><p>different persistent toxic pollutants. No sample was completely free of</p><p>industrial toxins, which is to be expected given how polluted our world has</p><p>become. What was surprising, though, was how minimal the differences</p><p>were between organically and conventionally produced meats. In some</p><p>cases, organic was inexplicably worse. Whether choosing conventional or</p><p>organic meat, the researchers concluded that the current pattern of meat</p><p>consumption exceeded the maximum tolerable safety limits either way.1139</p><p>Given that 90 percent of persistent pollutant exposure comes from</p><p>animal-derived foods,1140 it’s no surprise that those eating more low-</p><p>carbohydrate, high-protein-type diets have higher levels of pollutants</p><p>circulating in their systems. This included PCBs 118 and 153, trans-</p><p>nonachlor (a component of the banned pesticide chlordane),</p><p>hexachlorobenzene (a banned fungicide), DDE (from DDT), mercury, and</p><p>lead.1141 Mediterranean diet scores were correlated with elevated levels of</p><p>PCBs (118, 126, 153, and 209), trans-nonachlor, and mercury, presumably</p><p>because of the focus on fish consumption.1142</p><p>Any increase in body fat caused by obesogenic chemicals could</p><p>potentially serve as a reservoir for further chemical accumulation, possibly</p><p>setting up a vicious cycle.1143 Our fat stores—like those of farm animals—</p><p>harbor toxic pollutants. How do we know this? Because we see a surge in</p><p>these chemicals in people’s bloodstreams as they lose weight.1144 After</p><p>bariatric surgery, for example, certain pollutant levels can rise more than</p><p>300 percent.1145</p><p>The release of these compounds trapped in our body fat may then affect</p><p>our metabolisms, slowing down the rate at which we burn calories during</p><p>sleep, which could frustrate additional weight loss.1146 To help break this</p><p>cycle, a reduction in animal fat is suggested to reduce further accumulation</p><p>of pollutants, along with an increase in whole grains, as the fiber may help</p><p>draw toxins out of the body.1147</p><p>What About Organic Produce?</p><p>A recent expert review on obesogens suggests that doctors can help patients</p><p>reduce their exposure by advising them to choose organic fruits and</p><p>vegetables “insofar as possible.”1148 What evidence is there that the</p><p>pesticides used on produce may play a role in the obesity epidemic? Just as</p><p>the link between asbestos and disease first became apparent when studying</p><p>those with the greatest exposure—miners and shipbuilders—public health</p><p>researchers set out to study more than eight thousand licensed pesticide</p><p>applicators to see if there was any connection between crop pesticides and</p><p>weight gain.1149 One pesticide stood out, atrazine, the weed killer commonly</p><p>used in corn production that was found to induce complete feminization of</p><p>frogs—as in total sex reversal, with male frogs ending up laying eggs.1150</p><p>Agricultural workers spraying lots of atrazine had about 50 percent greater</p><p>odds of being overweight and obese.1151</p><p>Just because levels in the field may predispose people to obesity doesn’t</p><p>mean levels in the grocery store are high enough to have any effect, though.</p><p>To see if buying organic makes a difference, can’t we just compare the body</p><p>weights of those who choose organic to those who don’t? A study of more</p><p>than fifty thousand consumers did exactly that, and those who chose organic</p><p>“most of the time” only had about half the obesity rates of those who</p><p>“never” chose organic.1152 Your critical thinking alarm bells should have</p><p>started ringing instantly. Think of all the other attributes of organic</p><p>shoppers. Indeed, those choosing organic were better educated and better</p><p>off financially, both of which in and of themselves have been associated</p><p>with lower obesity risk,1153,1154 and, more to the point, exercised more and</p><p>had better diets. Those who chose organic ate more whole plant foods and</p><p>less meat, dairy, and junk. No surprise they had a healthier weight.</p><p>The researchers controlled for each of these other factors, however, and</p><p>still found dramatically lower obesity rates in “most of the time” organic</p><p>consumers, though not necessarily in those who just chose organic</p><p>“occasionally.”1155 Still, this was just a cross-sectional study, meaning a</p><p>snapshot in time. Rather than conventional foods contributing to weight</p><p>gain, maybe weight gain led people to throw up their hands and care less</p><p>about how their food was grown or produced.</p><p>In 2017, we got a prospective study where people were followed over</p><p>time. Sixty thousand French consumers were followed for about three years</p><p>to see if those choosing organic gained less weight. After controlling for</p><p>such factors as education, income, physical activity, and overall dietary</p><p>quality, those who reportedly ate more organic foods were significantly less</p><p>likely to become overweight or obese.1156 Note, though, that this was only</p><p>for those choosing healthier diets in general. Eating organic Oreos and Pop-</p><p>Tarts doesn’t do your body any favors.</p><p>Take-Home Tip: Personally, I try to choose organic whenever I have the option, but I never</p><p>let pesticide concerns prevent me or my family from indulging in as many fruits and</p><p>vegetables as possible regardless of how they were grown.</p><p>Microplastics in Seafood</p><p>In 1869, a patent was taken out on a new substance to replace elephant ivory in the production</p><p>of billiard balls, and the plastics industry was born.1157 What started as a conservation-minded</p><p>measure has turned into an environmental calamity.1158 Trillions of little plastic particles now</p><p>float on the surface of the sea.1159 Plastic objects like water bottles get worn down into tinier</p><p>and tinier pieces, and plastic microbeads in personal care products like facial cleansers flow</p><p>from our sinks down into the waterways. Up to ninety-four thousand microbeads are flushed</p><p>down the drain in a single rinse.1160</p><p>The plastic then accumulates toxic compounds from the water and shuttles them, along</p><p>with any chemicals originally in the plastic, into marine life, concentrating up the food chain</p><p>and eventually ending up on our plates.1161 This may explain how fresh cod can sometimes</p><p>end up with higher BPA levels than canned tuna.1162</p><p>It is inevitable that we’ll ingest at least some microplastics when we eat seafood,</p><p>particularly when the entire animal is consumed, such as with sardines.1163 Researchers</p><p>sampled twenty brands of canned sardines and sprats from thirteen countries over four</p><p>continents and found plastic particles in about one in five.1164 They suggested the disparities</p><p>may have been due to improper gutting in the contaminated samples, but in mammals, at least,</p><p>ingested microplastics can get through the gut wall, circulate throughout the body, and even</p><p>cross the placental barrier.1165</p><p>When researchers compared the level of microplastics in eviscerated flesh versus the guts</p><p>of fish, the meat sometimes actually contained higher microplastics loads than the excised</p><p>organs.1166 Some studies have detected microplastics in all fish muscle samples tested.1167</p><p>The average intake of microplastics from eating fish like flathead, grouper, shrimp scad, or</p><p>barracuda may be in the hundreds per serving or in the dozens of plastic particles in a two-</p><p>ounce, child-sized serving.1168 As the particles travel through our bodies, they may then</p><p>release any absorbed pollutants or plastics additives—some of which may play a role in the</p><p>obesity epidemic.1169 Because of this, some have suggested weekly servings of these kinds of</p><p>fish may threaten the health of consumers, especially vulnerable groups, such as children and</p><p>women who are pregnant or breastfeeding.1170</p><p>FOOD FOR THOUGHT</p><p>The obesogen field is still in its infancy but continues to gain scientific support.1171 The</p><p>American Medical Association, American Public Health Association, and the Endocrine</p><p>Society, the oldest and largest association of hormone specialists, have all called for</p><p>improved regulatory oversight of hormone-disrupting chemicals.1172 We don’t have to wait</p><p>to make simple diet and lifestyle changes to reduce our exposure, though. We can make a</p><p>difference now by prioritizing plant foods, opting for fresh or frozen vegetables over canned,</p><p>and, if eating or drinking out of polycarbonate and PVC plastics, choosing not to microwave</p><p>them, put them in the dishwasher, leave them in the sun or in a hot car, or use them once</p><p>they’re scratched,1173 as that can increase the release of the chemicals.</p><p>HIGH IN FIBER-RICH FOODS</p><p>Feeding Our Forgotten Organ</p><p>We used to think of food simply as a source of nutrients and energy, but we</p><p>now know there are components in what we eat that can act as signaling</p><p>molecules that bind to specific receptors within the body and trigger drug-</p><p>like effects to regulate our metabolisms, among other things. Ironically, one</p><p>of the food components that produces the most dramatic effects is</p><p>something that initially appeared to be the most inert of dietary constituents:</p><p>fiber.1174 In fact, telling people to increase their intakes of fiber-rich foods</p><p>may actually be one of the single most effective pieces of advice for weight</p><p>loss.</p><p>Fiber seems so, well, boring. By definition, fiber is indigestible. Since it</p><p>can’t be absorbed into the body, it just stays in our gut to bulk up our stool.</p><p>This is not to belittle the importance of bowel regularity. If just half the</p><p>adult population</p><p>ate three additional grams of fiber a day—only a quarter</p><p>cup of beans or a bowl of oatmeal—we could relieve enough constipation</p><p>to save billions in medical costs a year.1175 But it’s not as if we thought fiber</p><p>really did anything beyond helping to keep us regular.</p><p>While it’s true we can’t technically digest fiber, that’s only applicable to</p><p>the part of us that’s actually human. But most of the cells in our bodies are</p><p>bacteria.1176 Our gut flora, which weigh more than one of our kidneys and</p><p>are more metabolically active than our livers,1177 have been called our</p><p>“forgotten organ.”1178 And our good gut bacteria don’t just digest fiber—</p><p>they thrive on it. Fiber is like comfort food for your colon. So we can digest</p><p>fiber, just not without a little help from our little friends.</p><p>What do the bacteria do with the fiber? They make short-chain fatty</p><p>acids (SCFAs) with the fiber that can then be absorbed from the colon into</p><p>our bloodstreams, circulate throughout our bodies, and even end up in our</p><p>brains.1179 In this way, these fiber-sourced SCFAs can potentially have wide-</p><p>ranging effects on everything from immune function and inflammation1180 to</p><p>mental health1181—and, as you’ll see, may play a key role in regulating our</p><p>appetites, metabolisms, and body fat.1182</p><p>Crowding Out Calories</p><p>The first major review, “Dietary Fiber and Weight Regulation,” included a</p><p>dozen interventional studies in which people were randomized into higher-</p><p>or lower-fiber diets. The additional consumption of fourteen grams of fiber</p><p>a day led to an average weight loss of 1.9 kilograms over 3.8 months.1183</p><p>That’s only about a pound a month, but the weight loss was greater among</p><p>those who needed it; overweight and obese study subjects lost triple the</p><p>weight compared to lean individuals. How much is fourteen grams of fiber?</p><p>Not much. Fourteen grams would barely bring the average American’s diet</p><p>up to the recommended minimum average adequate daily fiber intake.1184</p><p>The increased fiber intake appeared to lead to about a 10 percent drop in</p><p>daily caloric intake.1185 Why would more fiber mean fewer calories? Well,</p><p>conventionally, fiber is considered to have zero calories, so it adds bulk to</p><p>food without adding extra calories. To illustrate, let’s compare a food to its</p><p>fiber-depleted equivalent. Consider a bottle of cold-pressed apple juice,</p><p>which is basically an apple with its fiber removed. You could chug a regular</p><p>15.2-ounce bottle of juice in a matter of seconds, but to get the same</p><p>number of calories, you would have to eat nearly five cups of apple</p><p>slices.1186,1187 Which do you think would fill you up more? Obviously, the</p><p>apple slices. But why?</p><p>First, you’d need to chew every apple slice. Fiber-rich foods require</p><p>more chewing, slowing down eating rate, which itself can improve</p><p>satiety.1188 This also allows for more secretion of saliva and stomach juices.</p><p>In one study, researchers spread a barium paste onto slices of different kinds</p><p>of bread and found that, upon x-ray, the stomach shadow was larger after</p><p>eating whole-wheat compared to white bread, showing how much fuller you</p><p>physically get.1189 So, in our cold-pressed apple juice versus apple slices</p><p>scenario, we have the extra fluid secretion on top of the five cups of slices</p><p>pushing on the walls of the stomach, which has nerves with stretch</p><p>receptors that can send fullness signals directly to the brain.1190</p><p>One type of fiber in apples is pectin, the gelling agent used to make jams</p><p>and jellies. Imagine how eating all those apples would not only add a lot of</p><p>extra bulky volume but could start to form a gel to further slow the rate at</p><p>which those five cups of slices left your stomach. This would keep you</p><p>feeling fuller for longer compared to consuming the same number of apple</p><p>calories in fiber-depleted juice form, which would pass right through you</p><p>much more rapidly. Other gummy fibers like those found in oats can have</p><p>the same gelling effect. Five grams of a highly gelling fiber can hold</p><p>approximately one quart of water as it passes through the stomach and</p><p>small intestine, so that’s like having an extra two pounds of zero-calorie</p><p>food mass filling you up.1191</p><p>Obviously, juice is going to drain out of your stomach faster than apples,</p><p>but even the same volume of fiber-depleted solid food exits more quickly.</p><p>In a study entitled “Gastric Emptying of a Solid Meal Is Accelerated by the</p><p>Removal of Dietary Fibre Naturally Present in Food,” researchers compared</p><p>how long it took for a meal that included higher-fiber foods—whole-wheat</p><p>pasta with puréed fruits and vegetables—to leave the stomach compared to</p><p>a meal with the same volume and same calories, but made from white pasta</p><p>and fruit and vegetable juices. The fiber-depleted meal was out of the</p><p>stomach forty-five minutes earlier than the meal with the fiber intact.1192</p><p>It’s Not the Calories You Eat but the Calories You Absorb</p><p>Now imagine what happens next: The apple juice would get rapidly</p><p>absorbed as soon as it spilled out from the stomach into the small intestine</p><p>and spike our blood sugars, whereas sugar trapped in the mass of apple</p><p>slices would be absorbed more slowly along the length of the intestine. Our</p><p>bodies can only absorb nutrients when they come in physical contact with</p><p>our intestinal walls, so fiber, which never gets absorbed, can act as a carrier</p><p>to dilute and even eliminate calories out the other end. Fiber doesn’t just</p><p>trap sugars; it can act as a fat-1193 and starch-blocker 1194 too. There are drugs</p><p>on the market that can do this, but eating fiber-rich foods can do it more</p><p>safely—and naturally.</p><p>What if you dipped those apple slices in peanut butter? Everything</p><p>would get mixed together, and some of the peanut oil calories would make</p><p>it all the way through the intestines, trapped in the middle of a gelled mass</p><p>of apple fiber. In contrast, if you ate a spoonful of peanut butter and then</p><p>washed it down with apple juice, the juice would get absorbed right off the</p><p>bat, leaving the peanut butter to coat the walls of the intestine and all the</p><p>calories to get absorbed. This has been demonstrated in experiments</p><p>measuring fecal fat excretion dating back nearly a half century.</p><p>What happens if you feed people white bread with butter versus whole-</p><p>wheat bread with butter, along with lots of fruits and vegetables, and</p><p>measure how much butter comes out the other end? The higher-fiber whole-</p><p>wheat group poops out more than twice as much fat as the white-bread</p><p>group,1195 since some of the butter calories get trapped in all that fiber. Even</p><p>if you just drink a third of a cup of oil on a high-fiber diet, you’d excrete</p><p>twice as much fat as you would on a low-fiber diet.1196 The same goes for</p><p>the calories of starch. Eat whole-grain bread as opposed to white bread, and</p><p>stool analyses will find that you flush out nearly ten times as many carb</p><p>calories.1197</p><p>It’s not what you eat but what you absorb, so you can lose more weight</p><p>on a high-fiber diet eating the exact same number of calories simply</p><p>because some of those calories get trapped and never make it into your</p><p>system. Those on a Standard American Diet lose about 5 percent of the</p><p>calories they eat in their waste,1198 but a higher-fiber diet can double that.1199</p><p>It’s not simply that the calories in high-fiber foods are less available. High-</p><p>fiber foods trap calories across the board. So eat a Twinkie on a high-fiber</p><p>diet and absorb fewer Twinkie calories! It’s like every calorie label you read</p><p>instantly gets discounted on a high-fiber diet.</p><p>We learn in school that a gram of protein has four calories, a gram of fat</p><p>has nine calories, and a gram of carbs has four calories—but that’s only on</p><p>a typical, low-fiber diet. On a higher-fiber diet, up around the average of</p><p>those eating completely plant-based diets,1200 the effective calorie counts</p><p>drop from 4-9-4 to around 3.5-8.7-3.8.1201 That may not seem like a lot, but</p><p>if Americans just reached the minimum recommended fiber intake, that</p><p>might decrease calorie absorption by more than one hundred calories a</p><p>day,1202 which may be enough to prevent</p><p>that average, gradual, annual</p><p>weight gain most experience through middle age.1203 Even a small,</p><p>consistent change in daily calorie absorption could potentially have long-</p><p>term significance for weight management.1204</p><p>Putting On the Brakes</p><p>A review entitled “Food Fibre as an Obstacle to Energy Intake”</p><p>summarized what I call the Four Ds by which dietary fiber results in</p><p>reduced caloric intake:1205 dilution of calories by expanding the volume of</p><p>food, distention of the stomach through fluid absorption, delay in stomach</p><p>emptying of the gelled mass, and dumping of calories by blocking the</p><p>absorption of other macronutrients, such as carbs and fat. That fourth D</p><p>triggers a fifth phenomenon known as the ileal brake.</p><p>The ileum is the last part of the small intestine before it empties into the</p><p>colon. When undigested calories are detected that far down our intestines,</p><p>our bodies put the brakes on eating more by curbing our appetites. This can</p><p>be shown experimentally. If you insert a nine-foot tube down people’s</p><p>throats and drip in protein, fat, or sugar, you can activate the ileal brake.</p><p>Then, if you sit them down to an all-you-can-eat meal, they will eat at least</p><p>one hundred fewer calories than those in the placebo group who had only</p><p>gotten a squirt of water through the tube.1206 Activating the ileal brake can</p><p>make people feel full up to nearly two hundred calories earlier.</p><p>Ever since its discovery, the ileal brake has been considered a medical</p><p>target for appetite control. So did doctors simply advise patients to eat lots</p><p>of whole, unprocessed plant foods so that the fiber would drag calories</p><p>down to activate the brake? Not quite. Instead, they developed the first</p><p>major bariatric surgery, the jejunoileal bypass.</p><p>Fiber-depleted foods get absorbed quickly and never make it all the way</p><p>down to the ileum, but instead of having people eat foods in their natural</p><p>form, some doctors decided just to cut out the intervening twenty or so feet</p><p>of intestine. By attaching the end of the ileum right up to within about</p><p>eighteen inches of the stomach, the ileal brake is activated no matter what</p><p>you eat. It’s like your emergency brake is always on. You can still drive, but</p><p>not as fast. So, with the jejunoileal bypass, you can still eat, but not as much</p><p>because you’re already feeling full.</p><p>More than twenty-five thousand patients underwent the procedure in the</p><p>United States before it was realized that cutting out 90 percent of the</p><p>intestines wasn’t such a good idea. The jejunoileal bypass resulted in long-</p><p>term progressive liver scarring in 38 percent of patients.1207 That’s nearly</p><p>two out of every five patients. Though the surgical approach failed, the</p><p>medical mind-set still prevails, with researchers teaming up with drug</p><p>companies and the food industry to exploit the ileal brake for weight loss</p><p>with “dietary encapsulation or slow release strategies,”1208 failing to</p><p>recognize that Mother Nature already designed a natural strategy in the</p><p>form of fiber-rich food.</p><p>Intestinal Workout</p><p>There are many ways eating more fiber means eating fewer calories, but the</p><p>“Dietary Fiber and Weight Regulation” review found that study subjects</p><p>randomized to consume higher-fiber diets lost more weight even when</p><p>caloric intake was fixed.1209 Think about it: more weight loss even when</p><p>prescribed the same number of calories. So if it wasn’t the calories-in side</p><p>of the equation, could it be the calories-out side? Normally, calories out</p><p>means things like exercise, but, in the case of high-fiber diets, there are</p><p>literally calories out—as in out the other end and flushed down the toilet.</p><p>But the same-calorie, higher-fiber groups were losing more weight even</p><p>after taking into account the excess calorie dumping. Where were the</p><p>calories going?</p><p>To solve the mystery of the missing calories, researchers fed people</p><p>different amounts of fiber and sealed them in an airtight chamber called a</p><p>whole-body calorimeter to closely monitor their metabolic rates.1210 Those</p><p>with more fiber in their systems burned more calories—even in their sleep.</p><p>Though it was only about 2 percent more, that translated into about fifty</p><p>more calories burned a day without getting out of bed. What was going on?</p><p>For people on long-term, fiber-rich diets, the researchers figured that all</p><p>that fiber might bulk up their intestinal linings, which are highly</p><p>metabolically active tissues. The gut may only represent 5 percent of body</p><p>weight, but it might burn 25 percent of daily calories.1211 Why were the</p><p>research subjects spontaneously burning off more energy even while they</p><p>were sleeping? It turns out all that extra fiber may be giving their gut a</p><p>workout.</p><p>Our intestines are muscular tubes, so our small intestines are essentially</p><p>twenty feet of muscle, which contract in waves to move food along. But</p><p>fiber-depleted foods don’t offer much resistance. Wonder Bread and apple</p><p>juice get absorbed almost immediately without much effort. It’s like</p><p>pumping iron with barbells made out of Styrofoam.</p><p>Researchers had people swallow long strings of electrodes to measure</p><p>the electrical activity of the muscular contractions of the intestines of those</p><p>eating low-fiber meals versus high-fiber meals.1212 Those eating more fiber</p><p>sometimes not only had stronger, faster, and longer contractions, but they</p><p>had also reduced the periods of intestinal inactivity. Turns out our gut can</p><p>be sedentary too. But if you eat lots of fiber-rich foods, your gut could be</p><p>exercising all night long while you sleep.</p><p>Discovering the Keys to Weight Loss</p><p>This laundry list of mechanisms for fiber-induced weight loss included the</p><p>best explanations we had back in 2001 when the “Dietary Fiber and Weight</p><p>Regulation” review was published, but that was two years before a</p><p>discovery was to change our ideas about fiber forever.1213</p><p>Cells are the fundamental unit of life. We’re composed of trillions of</p><p>them,1214 and they communicate with each other through receptors on the</p><p>cell surface. That’s how many hormones work: Like a lock and key,</p><p>hormones are signaling messengers, and each has a unique shape. When</p><p>released into the bloodstream, they circulate throughout the body until they</p><p>find a receptor they can fit into. Once the key is in the lock, a whole series</p><p>of reactions can be turned on or off in the target cell. For example, cells in</p><p>our adrenal glands release adrenaline when we get scared, and there are</p><p>receptors on our hearts, called beta receptors, into which adrenaline fits that</p><p>can trigger an increased heart rate. That’s how beta-blocker drugs work to</p><p>lower our heart rates—by gumming up this lock so adrenaline can no longer</p><p>fit.</p><p>The largest family of cell receptors is known as G protein–coupled</p><p>receptors. G proteins are molecular switches inside the cells that transmit</p><p>the receptor signal.1215 More than one-third of the drugs currently on the</p><p>market work by plugging into these receptors,1216 from antihistamines to</p><p>heroin overdose drugs that block opioid receptors. We’ve discovered</p><p>hundreds of different G protein–coupled receptors, but remarkably, we</p><p>don’t know what many of them do.1217 We have the lock, but we just don’t</p><p>know which key fits into them. Accordingly, these are called orphan</p><p>receptors.</p><p>Two of these mystery receptors, known only as G protein–coupled</p><p>receptor #41 and G protein–coupled receptor #43, were found heavily</p><p>expressed throughout the body in our gut, on our nerves, and in our</p><p>immune, muscle, and fat cells.1218 We knew they must be vital, but we didn’t</p><p>know what activated them until 2003 when they were “deorphanized.”</p><p>(That’s actually what scientists call it.) And the keys that fit into those</p><p>important locks were the short-chain fatty acids that our gut bacteria make</p><p>when we feed them fiber.1219</p><p>This may be how our gut bacteria communicate with us.1220 Renamed</p><p>free fatty acid receptors, their existence gives us crucial insight into how</p><p>fiber could play such a critical role in so many of our chronic diseases.1221</p><p>They may explain why fiber is so anti-inflammatory.1222 So, for example,</p><p>how can a single</p><p>high-fiber meal improve lung function in asthmatics</p><p>within a matter of hours? The fiber we eat is turned into SCFAs by our good</p><p>gut bacteria, which then are absorbed into our bloodstreams, where they are</p><p>thought to dock with these free fatty acid receptors found on inflammatory</p><p>immune cells in our airways, turning them off.1223</p><p>Hormones are defined as signaling messengers that are produced in one</p><p>organ, circulate through the bloodstream, and have a regulatory effect on</p><p>another organ. So these SCFAs could be considered hormones. It’s just that</p><p>the organs producing them are our microbiomes, the bacteria that populate</p><p>our gut. They can’t make these hormones without fiber, though. Just like</p><p>our bodies need iodine to make thyroid hormones and our thyroid function</p><p>suffers when we eat iodine-deficient diets, our bodies need fiber to make</p><p>short-chain fatty acids and can suffer the consequences if we eat fiber-</p><p>deficient diets.</p><p>Hacking Hunger Hormones</p><p>Short-chain fatty acids also stimulate the production of leptin,1224 the</p><p>hormone produced by fat cells to tell our brains to trim us down. Leptin is</p><p>an anorectic hormone, so called because it generates a loss of appetite and</p><p>weight, but it does so over the long term. Leptin levels slowly rise as the</p><p>volume of body fat gradually increases. In contrast, there are other anorectic</p><p>hormones that work rapidly, signaling our brains on more of a meal-to-meal</p><p>basis.1225 Two of these short-term appetite suppressants are PYY and GLP-</p><p>1, both of which are secreted by specialized L cells that line our colons</p><p>(named for their release of large packets of hormones).1226 Guess which</p><p>receptors are crowded all over the surface of L cells? Free fatty acid</p><p>receptors.1227</p><p>Drip some SCFAs onto L cells, and they start churning out PYY and</p><p>GLP-1. You can do this in a petri dish1228 or in a person, either by infusing</p><p>their rectums with an SCFA enema1229 or the old-fashioned way of feeding</p><p>people fiber1230 or, even better, fiber-rich foods.1231 These hormones then get</p><p>released into the bloodstream where they can shoot right up into the</p><p>appetite center of the brain and turn down our cravings.1232</p><p>The flip side to PYY and GLP-1 is ghrelin, the so-called hunger</p><p>hormone. Ghrelin levels rise in our blood before a meal to stimulate our</p><p>appetites and fall right down once we eat, before slowly building back up</p><p>again to propel us once more to the fridge.1233 But feed people twenty-four</p><p>grams of fiber, and four hours later, ghrelin levels are suppressed as much</p><p>as if they had just eaten five hundred calories’ worth of food.1234 Over the</p><p>longer term, overweight eleven- and twelve-year-olds who had been</p><p>randomized to increase fiber intake for sixteen weeks ended up eating</p><p>hundreds of fewer calories at a buffet meal challenge compared to a placebo</p><p>control group.1235</p><p>One of the most fascinating studies that has been done in this area</p><p>involves putting people into an fMRI machine that measures real-time brain</p><p>activity. Subjects were shown a high-calorie food such as a donut, and the</p><p>reward centers in their brains instantly lit up compared to when they were</p><p>shown a low-calorie food like cucumber slices. What happens if you repeat</p><p>the experiment, but this time, after secretly delivering SCFAs directly into</p><p>their colons? The subjects reported the high-calorie foods seemed less</p><p>appealing, and this was matched by decreased activity in some of the</p><p>reward centers in their brains, whereas their brains continued to react about</p><p>the same to the less-craveable foods.</p><p>The researchers figured this was due to PYY and GLP-1 secretion, but</p><p>that wasn’t the case: The effect was independent of hormone release. The</p><p>researchers speculated that perhaps they had directly stimulated free fatty</p><p>acid receptors on nerves in the gut that travel straight to the brain.1236</p><p>Similar results were not found with psyllium supplements (like</p><p>Metamucil),1237 which makes sense since psyllium is nonfermentable,</p><p>meaning our gut bacteria can’t eat it—so although it can improve bowel</p><p>regularity, it cannot be used to make the key ingredients for appetite</p><p>suppression.1238 Eat fiber-rich foods, though, and our good gut flora take the</p><p>fiber we eat and churn out molecules that calm our cravings.</p><p>Putting Fiber to the Test</p><p>The evidence for the role of fiber in weight control started with so-called</p><p>ecological studies.1239 These involve comparing population averages, noting</p><p>that populations with extraordinary fiber intakes tend to have negligible</p><p>obesity rates. The problem with dealing with population averages is that we</p><p>don’t know if the individuals eating the higher-fiber diets are themselves</p><p>necessarily the ones protected from obesity. In cross-sectional studies, you</p><p>can confirm in both adults1240 and children1241 that those who eat more fiber</p><p>are indeed significantly less likely to be obese. A problem with these types</p><p>of studies, however, is that they represent only a snapshot in time, so you</p><p>don’t know which came first, the obesity or the poor eating habits.</p><p>This brings us to cohort studies, where individuals and their diets can be</p><p>followed over time. A cohort study of overweight youth found that the</p><p>amount of fiber in a single, half-cup, daily serving of beans over about a</p><p>two-year period was associated with a “profound” 25 percent difference in</p><p>abdominal obesity.1242 In about the same time frame, in middle-aged</p><p>women, each two-gram increase in daily fiber was associated with a weight</p><p>decrease of about a pound.1243 The postpartum period places women at risk</p><p>for retaining baby weight,1244 and a study of hundreds of new moms</p><p>followed for the first five months found that inadequate fiber intake during</p><p>the postpartum period appeared to increase obesity risk by 24 percent. And</p><p>the benefits of fiber are not limited to women.1245 A cohort that included</p><p>tens of thousands of men who were followed for years concluded that a</p><p>daily ten-gram increase in fiber consumption might be expected to prevent</p><p>about 10 percent of weight gain within the population.</p><p>Overall, the evidence is strong from these kinds of observational studies</p><p>that “increasing consumption of dietary fiber with fruits, vegetables, whole</p><p>grains, and legumes across the life cycle is a critical step in stemming the</p><p>epidemic of obesity.”1246 These studies can control for nondietary influences</p><p>like physical activity by equipping people with gadgets to measure their</p><p>movement, but there may be uncontrolled confounding dietary factors.</p><p>Think about that list of high-fiber foods—fruits, vegetables, whole grains,</p><p>and beans. Maybe fiber intake is just a marker for the intake of healthy</p><p>foods. There are many reasons why eating whole plant foods could</p><p>facilitate weight loss that have nothing to do with fiber. To know if there’s a</p><p>cause-and-effect relationship between fiber and weight loss, you need to put</p><p>it to the test in interventional trials.</p><p>This is where rectal infusions come in handy.</p><p>In a randomized, double-blind, placebo-controlled crossover study,</p><p>researchers showed that by infusing SCFAs into people’s rectums, you can</p><p>boost their metabolisms within thirty minutes.1247 They used the amounts</p><p>you’d expect to create yourself from eating a high-fiber diet. Not only did</p><p>the subjects’ resting metabolic rate go up (that is, the amount of calories</p><p>burned just by being alive), but specifically, their fat oxidation jumped up,</p><p>too, increasing the amount of fat they were burning by more than 25</p><p>percent.1248 This translates into about an extra third of a pat of butter’s worth</p><p>of fat burned off their bodies within two hours of the infusion.1249</p><p>Colonic catheters aside, you can feed people SCFAs directly and get the</p><p>same little bump in resting metabolic rate and whole-body fat</p><p>breakdown,1250 in addition to decreasing appetite. So, again, fiber may work</p><p>on both sides of the energy-balance equation.1251 But does that decreased</p><p>appetite actually result in people eating less? Given the equivalent of about</p><p>ninety grams of fiber worth of SCFAs, study subjects consumed about two</p><p>hundred fewer calories</p><p>at an all-you-can-eat meal.1252,1253</p><p>Can’t you just feed people some beans? Indeed you can. Researchers in</p><p>Sweden fed people beans for dinner, and, by the next morning, after their</p><p>friendly flora had also had a chance to feast, their satiety hormones like</p><p>PYY were up, their hunger hormone ghrelin was down, and they reported</p><p>feeling less hungry.1254 The researchers didn’t measure subsequent food</p><p>intake, but a similar study with whole-grain rye for dinner led to a</p><p>decreased food intake at lunch the next day. Those who had eaten the fiber-</p><p>rich whole grain the night before felt fully satiated about one hundred</p><p>calories sooner at a meal more than twelve hours later.1255 So, by eating</p><p>fiber-rich foods on a daily basis, you can set yourself up for success.</p><p>What About Fiber Supplements?</p><p>Reduced caloric intake at a single meal or even over the course of a whole</p><p>day doesn’t necessarily translate into long-term weight loss, though, as our</p><p>bodies may find ways of compensating.1256 Experimentally delivering</p><p>SCFAs directly to the colon every day for months showed that it does</p><p>reduce abdominal fat, liver fat, and overall weight gain,1257 but what about</p><p>getting SCFAs the old-fashioned way, by taking fiber by mouth?</p><p>To isolate out the effects of fiber, studies have tried using straight fiber</p><p>supplements. A 2017 systematic review and meta-analysis compilation of a</p><p>dozen randomized controlled trials of various fiber supplements versus</p><p>placebo powders found that the groups taking the actual fiber lost an</p><p>average of about five and a half pounds more than the control groups.1258</p><p>These were studies ranging in duration from two to seventeen weeks,</p><p>though there have been fiber supplementation trials that have lasted up to a</p><p>year that have shown significantly superior weight changes in both young</p><p>adolescents1259 and adults.1260</p><p>Many of the fiber supplement findings were inconsistent,1261 though,</p><p>presumably because dozens of different isolated fiber types had been</p><p>tested.1262 There are all sorts of newfangled fibers on the market with names</p><p>like IQP G-002AS. (The IQP stands for InQpharm, the drug company that</p><p>came up with it.1263) After all, how much money can you make selling</p><p>beans?</p><p>Real Fiber FTW</p><p>Using isolated fiber extracted from plants or made in a lab can be useful in</p><p>experimentally proving fiber’s effectiveness apart from all the other healthy</p><p>components in whole foods, but, if anything, you might expect even greater</p><p>benefits from getting fiber the way nature intended: by eating intact plant</p><p>foods.1264</p><p>Published in the prestigious Annals of Internal Medicine, a study entitled</p><p>“Single-Component Versus Multicomponent Dietary Goals…” randomly</p><p>assigned hundreds of people into one of two weight-loss regimens:1265 One</p><p>simply encouraged people to get at least thirty grams of fiber each day,</p><p>which is about the recommended minimum adequate intake, and the other</p><p>advised people to also follow the far more complex weight-loss program</p><p>recommended by the American Heart Association. So, in addition to also</p><p>hitting that thirty-grams-of-fiber target, study subjects in the second group</p><p>were prescribed carefully calculated caloric intake goals and were told to</p><p>switch from red meat to white, moderate their alcohol intakes, cut down on</p><p>sugary beverages, and reduce sugar and sodium intake across the board.1266</p><p>Even though both groups were told to reach the same fiber target, the</p><p>group whose focus was solely on fiber intake ended up eating more than</p><p>twice as much extra fiber as the multicomponent intervention and,</p><p>surprisingly, similarly improved the quality of their diets. For example, the</p><p>group focused only on fiber intake ended up reducing their saturated fat</p><p>intakes as much as the group who was explicitly instructed to do so.1267</p><p>Simply telling people to eat more whole plant foods seems to naturally</p><p>crowd out some of the less healthy options by default. With similar dietary</p><p>improvements, both groups lost similar amounts of weight,1268 suggesting if</p><p>you could give only one piece of weight-loss advice, eating more fiber</p><p>might not be a bad choice. Of course, it only works if you actually do it.</p><p>There was one study that reported favorable results when eating a low-</p><p>carb diet compared to a “high-fiber” diet. But just how high was this so-</p><p>called high-fiber diet? The subjects started out at a pitiful 17.4 grams of</p><p>fiber a day. Sadly, that’s about typical for the United States,1269 but it’s only</p><p>about half the average recommended minimum daily intake of 31.5</p><p>grams.1270 The low-carb study subjects started out at 17.4 grams a day and,</p><p>on their “high-fiber” diets, shot up to … 18.6 grams a day. Seriously. In no</p><p>universe is that a high-fiber diet. Nevertheless, the low-carb study</p><p>researchers used their findings to conclude “previous claims of the benefits</p><p>of fiber for weight loss may have been overstated.”1271</p><p>Eating the Way Nature Intended</p><p>Fewer than 3 percent of Americans reach even the recommended minimum</p><p>daily adequate intake of fiber.1272 There’s so much fuss about protein, but</p><p>for that, the stats are reversed: More than 97 percent of Americans get</p><p>enough protein, but more than 97 percent of Americans don’t get enough</p><p>fiber. Nearly everyone is suffering from a fiber-deficient diet, and that’s just</p><p>based on the wimpy federal recommendations of fourteen grams per</p><p>thousand calories, which comes out to be about twenty-five grams per day</p><p>for women and thirty-eight daily grams for men.1273 That’s a far cry from</p><p>the hundred grams our bodies were designed to get,1274 based on the diets of</p><p>modern-day, isolated, hunter-gatherer tribes1275 and an analysis of</p><p>coprolites, human fossilized feces—paleopoo!1276</p><p>For perhaps more than 99 percent of our existence as a distinct species,</p><p>the natural state of affairs was having our guts literally packed with fiber-</p><p>filled foods all the time.1277 Before the gristmills and certainly for the</p><p>millions of years before the first stone tools and evidence of butchering, our</p><p>physiology evolved eating huge amounts of unprocessed plants.1278 That’s</p><p>the nutritional landscape upon which our bodies developed.</p><p>This could explain why our bodies centered this whole elaborate system</p><p>of body fat regulation around short-chain fatty acids, the microbial by-</p><p>product of fiber. Indeed, for most of our time on Earth, fiber equaled</p><p>food.1279 In fact, one of the theories used to explain the obesity epidemic is</p><p>that the body’s mechanisms for controlling appetite evolved to match our</p><p>ancestral diet.1280 It’s like a classic negative feedback loop (adapted from</p><p>Sleeth et al.).1281</p><p>Follow along in the diagram above, starting at the top (1). Imagine if we</p><p>ate too much of the foods we were designed to eat. Since, essentially, food</p><p>meant fiber, (2) our fiber intake would go up. The body would detect that</p><p>change because of (3) all the extra SCFAs flooding the system, which</p><p>would (4) activate the free fatty acid receptors all over the body, with direct</p><p>effects on our fat cells and brains, and indirect effects by (5) stimulating the</p><p>release of those anorectic hormones that (6) suppress our appetites. With</p><p>fewer cravings and less hunger, our (7) food intake would drop, which is</p><p>beneficial because, remember, we were (1) eating too much.</p><p>On our original, natural diet, a drop in food necessarily meant (8) a drop</p><p>in fiber intake, which our bodies would pick up on, because, all of a sudden,</p><p>there would be (9) less signaling by SCFAs and (10) less activation of those</p><p>free fatty acid receptors, which means (11) less of those anorectic hormones</p><p>circulating throughout our bodies, (12) perking up our appetites once again.</p><p>That may be how our bodies were meant to work to keep our body weight</p><p>stable.</p><p>Okay, but now, fast-forward past the Industrial Revolution and time-</p><p>machine drop the human body into the middle of bologna-on-Wonder-Bread</p><p>country. The figure above shows what happens when food doesn’t equal</p><p>high fiber anymore. When calories are divorced from fiber, we may just</p><p>keep getting these signals to eat, eat, and eat some</p><p>Kit Kat, Goobers, Gobstoppers, Runts, and Nerds.</p><p>Another of its slogans is “Good Food, Good Life.” Its Raisinets may have</p><p>some fruit, but the company seems to me more Willy Wonka than wellness.</p><p>Let’s just say that on its “What is Nestlé doing about obesity?” web page,</p><p>the “Read about our Nestlé Healthy Kids programme” link gave me a Page</p><p>Not Found error.37</p><p>The constant corporate drumbeat of overemphasis on physical inactivity</p><p>appears to be working. In response to a Harris poll question (“Which of</p><p>these do you think are the major reasons why obesity has increased?”), a</p><p>large majority (83 percent) chose lack of exercise, while only 34 percent</p><p>chose excessive calorie consumption.38 But blaming couch-potato-ness has</p><p>actually been identified as one of the most common misconceptions about</p><p>obesity.39 The scientific community has come to a fairly decisive</p><p>conclusion40 that the factors governing caloric intake far more powerfully</p><p>affect overall calorie balance.41</p><p>There’s even debate in the scientific literature as to whether changes in</p><p>physical activity had “any role whatsoever” in the obesity epidemic.42 The</p><p>increase in caloric intake per person is more than enough to explain the</p><p>U.S.43 and global44 epidemics of obesity. In fact, if anything, the level of</p><p>physical activity over the last few decades has gone up slightly in both</p><p>Europe and North America, rather than declined.45 Ironically, this bump</p><p>may be a result of the extra energy it takes to haul around our heavier</p><p>bodies, making changes in energy expenditure a consequence of the obesity</p><p>problem rather than the cause.</p><p>Formal exercise is only a small part of our total daily activity, though.</p><p>Think how much more physical work people used to do on the job, on the</p><p>farm, or even in the home.46 It’s not just the shift in collar color from blue to</p><p>white. Increasing automation, computerization, mechanization,</p><p>motorization, and urbanization have all contributed to increasingly more</p><p>sedentary lifestyles over the last century—and therein lies the problem with</p><p>the theory: The occupational shifts and advent of labor-saving devices have</p><p>been gradual and largely predate the dramatic, recent rise in weight gain the</p><p>world over.47 Washing machines, vacuum cleaners, and the Model T were</p><p>all invented before 1910. And indeed, when put to the test using state-of-</p><p>the-art methods to measure energy in and energy out, it was caloric intake,</p><p>not physical activity, that predicted weight gain over time.48</p><p>The common misconception that obesity is due mostly to lack of</p><p>exercise may not just be a benign fallacy, as personal theories of causation</p><p>appear to impact people’s weight. Those who blame insufficient exercise</p><p>are significantly more likely to be overweight themselves. Put them in a</p><p>room with chocolate, for instance, and they can be covertly observed</p><p>consuming more candy compared to those who put the onus of obesity on</p><p>poor diet.49 But you can’t know if such attitudes are playing a role in their</p><p>weight problem until you put it to the test. So researchers randomized</p><p>people to read a fictitious article implicating inactivity in the rise of obesity</p><p>and found they indeed went on to eat significantly more sweets than those</p><p>who instead were given an article that indicted diet.50 A similar study</p><p>evidently found that those presented with research blaming genetics</p><p>subsequently ate significantly more cookies. The paper was entitled “An</p><p>Unintended Way in Which the Fat Gene Might Make You Fat.”51</p><p>Do These Genes Make Me Look Fat?</p><p>To date, about one hundred genetic markers have been linked to obesity, but</p><p>when you put all of them together, they account for less than 3 percent of</p><p>the difference in body mass index between people.52 The “fat gene” you</p><p>may have heard about (called FTO, short for “FaT mass and Obesity</p><p>associated”) is the gene most strongly linked to obesity,53 but it explains less</p><p>than 1 percent of the difference between people (a mere 0.34 percent).54</p><p>FTO codes for a brain protein that appears to affect your appetite.55 Are</p><p>you one of the billion people on Earth who carry a full complement of FTO</p><p>susceptibility genes?56 It doesn’t really matter, because this only appears to</p><p>result in a difference in intake of a few hundred extra calories a year,57</p><p>while what it took to lead to the obesity epidemic is more like a few</p><p>hundred calories a day.58 FTO is the gene so far known to have the most</p><p>effect on excessive weight gain,59 but the chances of accurately predicting</p><p>obesity risk based on FTO status are only slightly better than flipping a</p><p>coin.60</p><p>When it comes to obesity, the power of your genes is nothing compared</p><p>to the power of your fork. Even the small influence the FTO gene does have</p><p>appears to be weaker among those who are physically active61 and may be</p><p>abolished completely in those eating healthier diets. FTO only appears to</p><p>affect those eating diets higher in saturated fat (predominantly found in</p><p>dairy, meat, and junk food). Those eating more healthfully appear to be at</p><p>no greater risk of weight gain even if they inherited the “fat gene” from</p><p>both their parents.62</p><p>Physiologically, FTO gene status doesn’t appear to affect your ability to</p><p>lose weight.63 Psychologically, knowing you’re at increased genetic risk for</p><p>obesity may motivate some people to eat and live more healthfully,64 but it</p><p>may cause others to fatalistically throw their hands up in the air and resign</p><p>themselves to thinking it just runs in their families.65 Obesity does tend to</p><p>run in families, but so do lousy diets.</p><p>Comparing the weight of biological versus adopted children can help</p><p>tease out the contributions of lifestyles versus genetics. Children growing</p><p>up with two overweight biological parents were found to be 27 percent</p><p>more likely to be overweight themselves, whereas adopted children placed</p><p>in a home with two overweight parents were only 21 percent more likely to</p><p>be overweight.66 So genetics certainly play a role, but this suggests that it’s</p><p>more the children’s environment than their DNA.</p><p>Diet Trumps Genes</p><p>One of the most dramatic examples of the power of diet over DNA comes from the Pima</p><p>Indians of Arizona, who have among the highest rates of obesity67 and diabetes68 in the world.</p><p>This has been ascribed to their relatively fuel-efficient genetic makeup.69 Their propensity to</p><p>store calories may have served them well in times of periodic scarcity when they were living</p><p>off the land, but when the area became “settled,” their source of water, the Gila River, was</p><p>diverted upstream. Those who survived the ensuing famine70 had to abandon their traditional</p><p>diet to live off government food programs, and chronic disease rates skyrocketed.71 Same</p><p>genes, but a different diet, leading to a different result.</p><p>In fact, a natural experiment was set up. The Pima living across the border in Mexico come</p><p>from the same genetic pool but were able to maintain more of their traditional lifestyle,</p><p>centered around the food staples known as the three sisters: corn, beans, and squash.72 Same</p><p>genes, but about five times less diabetes and obesity.73</p><p>Genes may load the gun, but diet pulls the trigger.</p><p>Survival of the Fattest</p><p>It’s been said: “Nothing in biology makes sense except in the light of</p><p>evolution.”74 The known genetic contribution to obesity may be small, but</p><p>in a certain sense, you could argue it’s actually all in our genes. That’s</p><p>because the excess consumption of available calories may be hardwired into</p><p>our DNA.</p><p>We were born to eat. Throughout most of human history and beyond, we</p><p>existed in survival mode, in a context of unpredictable scarcity, so we’ve</p><p>been programmed with a powerful drive to eat as much as we can, while we</p><p>can, and just store the calories we don’t need right away on our bodies for</p><p>later. Food availability could never be taken for granted, so those who ate</p><p>more in the moment and were best able to store more fat for the future</p><p>might better survive subsequent shortages to pass along their genes.</p><p>Generation after generation, millennia after millennia, those with lesser</p><p>appetites may</p><p>more. We’re always</p><p>hungry because our bodies aren’t getting the signal that we’ve eaten</p><p>enough, even though we’re piling in the calories. If we haven’t eaten our</p><p>hundred grams of fiber for the day, our bodies may be like, What? Are we</p><p>starving here?</p><p>Sadly, the average fiber intake in the United States has failed to improve</p><p>in recent years despite ongoing public health messaging about its</p><p>importance.1282 One problem may be that people just don’t know what fiber</p><p>is. More than half of Americans surveyed think steak is a significant source</p><p>of fiber.1283 However, literally by definition, fiber is only found in plants.1284</p><p>There is zero fiber in meat, dairy, or eggs and typically little or no fiber in</p><p>junk food.</p><p>Therein lies the problem.</p><p>Ninety-six percent of Americans don’t eat the minimum recommended</p><p>daily amount of beans, 96 percent don’t eat the measly minimum for greens,</p><p>and 99 percent don’t get enough whole grains.1285 Nearly the entire U.S.</p><p>population fails to eat enough whole plant foods—the only place fiber is</p><p>naturally found in abundance. You know things are bad when french fries</p><p>make it into the top ten sources of fiber in the American diet,1286 and donuts,</p><p>cookies, and cake come in at number thirteen. In comparison, sweet</p><p>potatoes are down at number forty-seven. And what’s the number-one</p><p>source of fiber in the American diet? Ironically, it’s white bread. Even</p><p>though it’s severely fiber-depleted, we eat so much of it and so few whole</p><p>grains and beans that white bread is Americans’ top fiber source.</p><p>You’d think the discovery of the free fatty acid receptor mechanism for</p><p>appetite control would reignite the public health push to get us all to eat</p><p>healthier food, but instead, Big Food and Big Pharma view it as an</p><p>opportunity to market new products. Since “large amounts of dietary fibre</p><p>(>30g/day)”—in other words, the recommended minimum adequate intake</p><p>—“are required for these beneficial effects,”1287 researchers conclude,</p><p>“alternative ways of optimising colonic SCFA production may be</p><p>needed.”1288 The measly minimum represents “unpalatably high levels,”1289</p><p>according to these drug industry–funded researchers. Thus, there are calls</p><p>for “pharmacological manipulation of appetite using a GPR43 agonist</p><p>[stimulator].”1290 Their conclusion is that “activation of colonic [free fatty</p><p>acid receptor] FFA2 by … pharmacological mimetics [mimickers] is a</p><p>promising candidate in the fight against the current obesity onslaught.”1291</p><p>Or we could just eat as nature intended.</p><p>FOOD FOR THOUGHT</p><p>What are the best sources of fiber? The American Medical Association published a patient</p><p>summary about fiber-rich foods listing an array of whole, unrefined plant foods.1292 Those of</p><p>us who may be a little smug about our hearty intake of fruits and vegetables need to realize</p><p>that fruits and leafy veggies are the poorest whole-food sources of fiber. Why? Because</p><p>they’re 90 percent water. Root vegetables have about twice as much on a per-weight basis,</p><p>but the fiber superstars are whole grains and legumes, which include dried or canned beans,</p><p>split peas, chickpeas, and lentils.1293</p><p>HIGH IN WATER-RICH FOODS</p><p>Mouthwatering</p><p>Like fiber, water adds bulk to foods without adding calories. A prune and a</p><p>plum are pretty much the same—one just has more water. You could eat a</p><p>whole handful of prunes as a snack, but the same number of plums would</p><p>be an armload. In a famous experiment, dozens of common foods were</p><p>scored for their ability to satiate the appetites of individuals for hours, and</p><p>the characteristic most predictive of satiety in general was water content.1294</p><p>Grapes, for example, have less fiber than bananas but were significantly</p><p>more satiating—perhaps in part because of their greater water content.1295</p><p>Apples and oranges, which have even higher water content, beat out both</p><p>grapes and bananas, but researchers fed people up to twice as much to</p><p>match them calorie for calorie. So, in effect, they found that four oranges</p><p>were more satiating than two bananas, which seems kind of obvious, but the</p><p>size difference is exactly the point. Because apples and oranges are about</p><p>85 percent water, you have to eat a lot more of them to get the same number</p><p>of calories.1296</p><p>People tend to eat a fairly consistent weight of food on a day-to-day</p><p>basis, and serving weight is largely determined by water content.1297 The</p><p>more water-rich the food, the fewer calories are being taken in overall.</p><p>Higher-volume foods also take longer to eat, which slows the rate of</p><p>consumption and increases “oropharyngeal stimulation,”1298 the sensation of</p><p>food in our mouths and throats. The more we chew, taste, and feel food in</p><p>our mouths, the more our brains get tipped off that we’re filling up.</p><p>Stomach tube studies in which food bypasses the mouth show that the body</p><p>has difficulty regulating appetite when we don’t experience those oral</p><p>sensations.1299</p><p>Which foods have the most water? On the next page, I’ve put together a</p><p>ranking for you of the water content of common foods.1300</p><p>As you can see, vegetables top the charts, with most being more than 90</p><p>percent water by weight, followed by most fruit coming in around the 80s.</p><p>Starchier vegetables, whole grains, and canned beans are in the 70s,</p><p>meaning about three-quarters of their weights are pure water. Pasta and</p><p>most unprocessed meat, including seafood, fall down to the 60s. Most dried</p><p>fruits, cheeses, and breads are in the 30s. Cake crumbles into the 20s,</p><p>cookies into the teens, and candy and most common snack foods are all the</p><p>way at the bottom with less than 9 percent water by weight. In general,</p><p>when it comes to water-rich foods, most whole plant foods float up near the</p><p>top, most animal foods fall somewhere in the middle, and most processed</p><p>foods sink to the bottom.</p><p>Trapped vs. Free Water</p><p>Can’t you just drink a few glasses of water while you eat a steak and make</p><p>up for the meat’s low water content that way? If you drank ten gulps of</p><p>water with every bite, wouldn’t you end up with the same 95 percent water</p><p>stomach contents you’d get eating, say, cucumbers and lettuce? This</p><p>scheme works for fat cats—adding water to dry kibble can help our pet cats</p><p>lose weight1301—but it doesn’t seem to work for dogs.1302 So are we more</p><p>like dogs or cats?</p><p>If you have people drink two glasses of water with a meal, their</p><p>subjective feelings of hunger and satiety can be affected. This led</p><p>researchers to suggest that drinking extra water could decrease food intake</p><p>in a manner “far more simple and cheaper than installing an intragastric</p><p>balloon.”1303 Drinking water with meals would certainly be safer, but it</p><p>doesn’t appear to actually cut down on food intake.1304 People tend to feel</p><p>fuller when they drink water with a meal, but that doesn’t appear to actually</p><p>translate into eating less.1305</p><p>Why does water inside a food reduce intake, but not water alongside a</p><p>food? It all just ends up in the same place, right? What appears to be</p><p>happening is a phenomenon known as sieving.1306 When water is outside the</p><p>food, the stomach simply siphons it off from the solid chunks and strains it</p><p>right out, which leads to a rapid drop in stomach volume. On the other</p><p>hand, when water is part of a food, it all forms a homogenous mass that</p><p>more slowly empties from your stomach over time.1307</p><p>If you give people a casserole for lunch, they eat the same amount</p><p>whether or not they’re also given a glass of water, about four hundred</p><p>calories’ worth. But if that same casserole and that same water are blended</p><p>into a soup, they only eat three hundred calories’ worth before feeling</p><p>full.1308 You can do real-time MRI scans of people’s stomachs and witness</p><p>the sieving process in action. A half hour after eating, the stomach volume</p><p>remained 36 percent greater after eating the same meal in soup form.1309</p><p>Blended together, the same meal components served as a soup left people</p><p>significantly fuller even three hours later.1310</p><p>Even though the soup was puréed in a blender, its thickness from all the</p><p>little suspended particles prevented the stomach from separating</p><p>out the</p><p>water and draining it off.1311 It even works with thinner liquids.1312 If you</p><p>give people a milkshake followed by a glass of water, the body is able to</p><p>layer out the water and empty the stomach twice as fast than if you had</p><p>preblended in the water to make a more dilute, thinner shake. This helps</p><p>explain observational data showing that, compared to water consumed</p><p>separately, the intake of water in foods is more closely related to a slimmer</p><p>waist.1313</p><p>Does Dried Fruit Make You Gain Weight?</p><p>Some dried fruit is as dry as beef jerky. Drying concentrates the calories. Compared to dried</p><p>fruit, fresh fruit gives us more volume, more weight—more food—for the same number of</p><p>calories.1314 Drying also concentrates the sugars, which could drive overeating. The raisin</p><p>industry is quick to point out that raisins don’t cause any more of a sugar spike than when</p><p>consuming the same number of calories of grapes, but with grapes, that means eating about</p><p>four times as much food.1315 On the other hand, in dried fruit, the fiber also gets more</p><p>concentrated, which could potentially aid satiety. So which is it?</p><p>In population studies, those who eat dried fruit tend to be slimmer than those who</p><p>don’t,1316 but they also tend to eat better diets overall. This is one reason interventional</p><p>studies are so important to prove whether there’s a cause-and-effect relationship. Leave it to</p><p>the California Raisin Marketing Board to dream up a study entitled “An After-School Snack</p><p>of Raisins Lowers Cumulative Food Intake in Young Children.”1317 Sounds good, right? Well,</p><p>what did they compare raisins to? Potato chips and chocolate chip cookies. They gave kids</p><p>raisins, grapes, chips, or cookies and told them to eat as much as they wanted. Surprise,</p><p>surprise, the kids ate less fruit and more junk. To be fair, I guess naming the paper “Kids</p><p>Prefer Cookies” would not have garnered the same kind of sponsor approval.</p><p>Give people fresh fruit, and they end up eating less at subsequent meals. Give people</p><p>strawberries, raspberries, blackberries, and blueberries, and they eat less pasta an hour later</p><p>compared to those given the same number of calories in the form of gummy bears, which have</p><p>about the same water content as raisins.1318 The same effect can be found with other kinds of</p><p>fresh fruit,1319 and this can translate into greater weight loss. Give people apples or pears</p><p>every day instead of the same calories in cookies, and they lose significantly more weight.1320</p><p>The only way to know if water content played the critical role, though, is if the researchers</p><p>had included a third group in the study who had been given dried pears and apple rings.</p><p>There have been experiments directly comparing raisins to grapes. Although grapes appear</p><p>to suppress appetite better than raisins,1321 raisins beat out grapes when it came to reducing</p><p>pizza intake a half hour later. I know as parents there’s a concern that if our kids eat snacks, it</p><p>might spoil their dinners, but when the snacks are fruit and the meal is “pepperoni and 3</p><p>cheese pizza,”1322 perhaps the more we can ruin their appetites, the better.</p><p>Does the satiating effect of raisins translate into weight loss, though? Prunes can also cut</p><p>down on appetite1323 and subsequent meal intake,1324 but feed people about nine prunes a day</p><p>and they don’t appear to lose any weight, at least in the short term (though their bowel habits</p><p>did improve).1325 Similarly, replacing about four hundred to five hundred calories of</p><p>someone’s diet with raisins every day may not lead to weight loss. However, you can imagine</p><p>how adding the same caloric load in the form of grapes every day—four or five cups—might</p><p>have more of an effect.1326 Bottom line: Although eating dried apples,1327 figs,1328 dates,1329</p><p>prunes,1330 or raisins1331 may not lead to inordinate weight gain, they don’t appear to actively</p><p>promote weight loss. That makes fresh fruit the better choice.</p><p>FOOD FOR THOUGHT</p><p>Take a deep dive into the Water Content of Foods chart so your diet swims in water-rich</p><p>vegetables and juicy fruit (though not the gum!).</p><p>LOW GLYCEMIC LOAD</p><p>Chew on This</p><p>One of the major dietary shifts from the ancient to the modern world has</p><p>been the increased consumption of fiber-depleted processed carbohydrates</p><p>—sugars and starches.1332 The impact of carbs on the body depends on their</p><p>source. Kidney beans and jelly beans are both rich in carbs but can have</p><p>diametrically different impacts on our bodies. Bread made from the exact</p><p>same ingredients as pasta causes nearly twice the blood sugar spike, leading</p><p>to nearly three times the insulin release as the same number of carbs</p><p>consumed in noodle form.1333 That’s because bread is filled with tiny</p><p>bubbles, allowing digestive enzymes easy access to more surface area to</p><p>more rapidly digest starch into sugars compared to pasta, which is more</p><p>compact. The more solid nature of pasta forces the enzymes to have to work</p><p>their way in from the edges, slowing the rate at which pasta can be broken</p><p>down.</p><p>You can try this experiment at home: Take a bite of a piece of bread, and</p><p>chew, chew, and chew some more without swallowing. Gradually, that piece</p><p>of bread will taste sweeter and sweeter, thanks to the starch-digesting</p><p>enzyme in our saliva. Next, try it with cooked spaghetti. Sore jaw alert! It</p><p>may take two hours of chewing pasta to get the same sweetness in your</p><p>mouth that you’d get from chewing bread for only ten minutes. You</p><p>probably won’t want to try it with the whole intact grain—wheat berries—</p><p>because it might take all day.1334</p><p>Why do we care how quickly carbohydrates are digested? Because it can</p><p>affect our appetites, our metabolic rates, and how much fat we burn.</p><p>You can measure the impact different carbohydrate-rich foods have by</p><p>feeding people a certain amount and seeing what happens to their blood</p><p>sugar levels over the next few hours. Then you can compare the size of the</p><p>blood sugar bump from the carbs in bread form to the same number of carbs</p><p>in pasta form, or fruit form—or cotton candy form, for that matter. This is</p><p>how the glycemic index of foods is generally calculated. Then, based on the</p><p>number of carbs per serving, we can come up with the glycemic load of a</p><p>food. The higher the glycemic load, the higher our blood sugars tend to</p><p>spike when we eat them. A breakdown of some common sweet and starchy</p><p>foods appears here.1335</p><p>Lighten Your Load</p><p>If you feed people two types of meals matched for calories, nutrition, and</p><p>taste, but one has a high glycemic load and the other low, what happens</p><p>when you put them in a brain scanner? The high-glycemic-load meal causes</p><p>significantly greater activation in the regions of the brain associated with</p><p>reward and craving, along with increased hunger four hours later.1336 This</p><p>may help explain why most of the top dozen problematic foods identified in</p><p>a study entitled “Which Foods May Be Addictive?” were high-glycemic-</p><p>load foods. (I expand on this study in the Low in Addictive Foods section.)</p><p>Rather than the quantity of refined carbs, such as white flour and sugar, it</p><p>was the speed at which they were absorbed in the system that was more</p><p>predictive of being “addictive.”1337</p><p>What do you think happened when kids ate Corn Flakes, Coco Pops, or</p><p>Rice Krispies for breakfast versus a lower-glycemic-load food like oatmeal</p><p>with a spoonful of sugar? After the high-glycemic breakfast, the kids went</p><p>on to eat more of a buffet-style lunch than when they had started their day</p><p>eating about the same number of calories of the lower-glycemic breakfast.</p><p>Even with the extra sugar added to their oatmeal, they ended up eating</p><p>about one hundred fewer calories of the all-you-can-eat lunch, compared</p><p>with after the high-glycemic breakfast.1338 In this case, the difference in</p><p>fiber intake also could have played a role, but in general, these types of</p><p>short-term satiety studies have shown that lower-glycemic carbohydrates</p><p>may make one feel fuller longer.1339</p><p>Beyond appetite regulation, lower-glycemic-load foods can also cause</p><p>you to burn more fat. If you feed people a low-glycemic</p><p>meal (All-Bran</p><p>cereal and fruit) and put them on a treadmill three hours later, they burn</p><p>more fat than they would after having eaten the same number of calories of</p><p>a high-glycemic meal (for example, Corn Flakes and white bread).1340 This</p><p>enhanced fat loss can occur not only during brisk walking1341 or running1342</p><p>but can happen even when doing nothing.</p><p>One of the reasons it’s so hard to maintain weight loss is that our bodies</p><p>try to defend themselves against losing fat by slowing down our resting</p><p>metabolic rates, the number of calories our bodies burn every hour just by</p><p>existing.1343 That’s one of the reasons weight loss can stall on a diet. But put</p><p>people on a low-glycemic-load diet, and metabolic rate doesn’t slow down</p><p>as much—their metabolisms slow by 96 calories a day after losing about</p><p>twenty pounds, compared to a metabolism that is 176 calories slower on a</p><p>higher-glycemic-load diet.1344 An 80-calorie-a-day difference might not</p><p>seem like a lot, but those calories are burned automatically without an</p><p>ounce of additional effort on our parts. Eighty calories is about how much</p><p>we’d burn walking an extra mile a day (or eating about two fewer bites of a</p><p>donut).</p><p>This process can work the other way too. If you overfeed people on a</p><p>high-glycemic diet, then they store more fat than those eating the same</p><p>number of calories of a low-glycemic diet. If you eat 50 percent more</p><p>calories than needed, you add about a quarter pound of pure fat to your</p><p>body each day on a high-glycemic diet. However, if you eat the same</p><p>number of extra calories on a low-glycemic diet, you gain about 40 percent</p><p>less,1345 which comes out to a difference of about a pound of fat a week</p><p>while eating the same number of calories.</p><p>Putting Lower-Glycemic Eating to the Test</p><p>Between the satiating power and metabolic benefits of low-glycemic foods,</p><p>it’s no wonder that those randomized to be given lower, rather than higher,</p><p>glycemic meals appear to lose more body fat.1346,1347 What did surprise me</p><p>was how underwhelming the evidence was for significant or long-term</p><p>weight loss with low-glycemic-load interventions. A review prepared by the</p><p>Cochrane Collaboration, historically considered to be the evidence-based</p><p>gold standard, concluded that “lowering the glycaemic load of the diet</p><p>appears to be an effective method of promoting weight loss” but only found</p><p>the benefit to be a few extra pounds of weight loss after weeks or months on</p><p>lower-glycemic-load diets.1348</p><p>The DIOGENES trial is held up by advocates of lower-glycemic eating</p><p>as evidence of its efficacy.1349 Hundreds of overweight individuals were</p><p>advised to eat either higher- or lower-glycemic index diets after losing an</p><p>average of twenty-four pounds to see who could keep off the weight better.</p><p>Those on lower-glycemic diets regained less weight at six months compared</p><p>to those on the high-glycemic-index diet, but it was only two pounds</p><p>less,1350 and the benefit appeared to effectively vanish by the one-year</p><p>mark.1351 In retrospect, this is unsurprising given how unsuccessful they</p><p>were at convincing people to change their eating habits.</p><p>Anytime findings in controlled feeding studies don’t seem to translate</p><p>into real-world results, the first question you always have to ask is: Did the</p><p>subjects actually follow the prescribed diet? In a controlled setting like in</p><p>that metabolic rate study, the glycemic load can be dropped 70 percent,</p><p>from a total daily glycemic load of 287 down to 82. In the case of the</p><p>DIOGENES trial, where people were randomized not to different diets but</p><p>to different dietary recommendations, the difference in daily glycemic loads</p><p>between the “high” glycemic group and the “low” glycemic group differed</p><p>by less than 3 percent.1352 No wonder the demonstrated benefits were slim to</p><p>none. Foods only work if you eat them.</p><p>Even in the most successful studies, it’s hard to separate out the specific</p><p>effects of the glycemic change. Many high-glycemic foods are highly</p><p>processed and fiber-depleted, so when you swap them for low-glycemic</p><p>foods like beans and fruit, you’re doing more than just changing the</p><p>glycemic load. The big drop in glycemic load in the metabolic rate study</p><p>was accompanied by a similar-sized boost in fiber intake—so how do we</p><p>know it was the glycemic load and not the fiber?1353 That’s the problem with</p><p>diet studies: It’s hard to change just one thing. With drug trials, it’s easy—</p><p>just give the drug or a sugar pill and if there’s a change, you know it was</p><p>the drug that caused it. If only we could stuff the change in glycemic load</p><p>into a pill. Well, it turns out we can.</p><p>Acarbose is a drug that partially blocks our sugar- and starch-digesting</p><p>enzymes in the digestive tract, slowing their absorption into the body.1354</p><p>When taking the drug with a meal, you can effectively transform a high-</p><p>glycemic meal into a low-glycemic meal without changing the foods at</p><p>all.1355 Weight-loss trials with acarbose offer the strongest case that simply</p><p>lowering dietary glycemic load may indeed be beneficial for weight</p><p>management.1356,1357</p><p>FOOD FOR THOUGHT</p><p>As you can see in the Glycemic Load Per Serving chart, the simplest way to stick to a lower-</p><p>glycemic diet is to try to stick to foods that were grown, not made. If you are going to eat</p><p>high-glycemic foods, though, there are ways to help blunt the blood sugar spikes. I explore a</p><p>few options in part IV, where I cover a series of weight-loss boosters, including the use of</p><p>vinegar in the Amping AMPK section and choosing intact grains over whole ones in the Wall</p><p>Off Your Calories section.</p><p>You can also eat berries with your meals, which can act as starch blockers by inhibiting</p><p>the enzyme that digests starch.1358 This slows the absorption of blood sugars into your</p><p>system. So, if you are going to sit down to a high-glycemic breakfast, put a raspberry spread</p><p>on your toast, add strawberries on your cornflakes, or make your pancakes blueberry, for</p><p>example, to help mediate the glycemic rush.</p><p>Some starch is naturally resistant to digestion. Prior to the discovery of this “resistant</p><p>starch” in 1982, we thought all starch could be broken down by the enzymes in our small</p><p>intestines.1359 Now we know there are indeed starches that resist digestion, which not only</p><p>lowers their glycemic impact but, since they make their way down to our large intestines, can</p><p>act as prebiotics to feed our good bacteria, just like fiber does. (Probiotics are live bacteria;</p><p>prebiotics are the fuel that feeds them.) Resistant starch is found naturally in many common</p><p>foods, including beans, grains, vegetables, seeds, and some nuts—but in small quantities, just</p><p>a few percent of the total.1360 There are ways, though, to get more resistant starch into your</p><p>diet.</p><p>When regular starches are cooked and then cooled, some of the starch recrystallizes into</p><p>resistant starch. For this reason, pasta salad can be a bit healthier than hot pasta, and potato</p><p>salad sometimes healthier than a baked potato. But the effect isn’t huge. The resistant starch</p><p>goes from about 3 percent up to 4 percent. So rather than relying on cold starches, the best</p><p>source of resistant starch is legumes—beans, split peas, chickpeas, and lentils—which start</p><p>out at 4–5 percent and then go up from there.1361</p><p>LOW IN ADDED FAT</p><p>The Fat Wars</p><p>Dueling Time magazine covers, one depicting an egg-and-bacon frowny</p><p>face and another exhorting people to eat butter, exemplify the two</p><p>battlefronts in the contentious issue of dietary fat’s role in disease. On one</p><p>side, all sources of fat are villainized, while on the other, lard is lauded. As</p><p>is so often the case with fervent partisan positions, both could stand a dose</p><p>of science.</p><p>A common trope of the pro-fat faction is that the obesity epidemic was</p><p>fueled by government calls to reduce fat intake. This presupposes the</p><p>American public actually followed that advice. In fact, fat intake has not</p><p>fallen; it’s gone from an estimated average of 743 daily calories of fat in the</p><p>1970s to 747 in the latest national survey.1362 The availability of added fats</p><p>and oils rose more</p><p>than 50 percent, from 52.5 pounds per person in 1970 to</p><p>82.2 in 2010.1363 America presumably got fat because we ate more of</p><p>everything—more carbs, more protein, and more fat.1364 We now eat about</p><p>500 more calories every day and gained about an extra 500-calories-a-day’s</p><p>worth of weight.1365 So there’s no great mystery there.</p><p>The percentage of calories from fat decreased from about 37 percent to</p><p>34 percent, but that’s just because the increase in carbs and protein</p><p>exceeded the increase in fat. At no time in recent history has America eaten</p><p>a low-fat diet.1366 The pro-fat faction is right about one thing, though: The</p><p>food industry’s response to the call to reduce fat may have made things</p><p>worse.</p><p>The low-fat diet recommendation, as proposed in the original Dietary</p><p>Goals for the United States, was intended, for example, to “decrease</p><p>consumption of meat”1367 and increase consumption of naturally low-fat</p><p>foods, such as fruits, vegetables, and whole grains.1368 But how much</p><p>money can be made on millet? Not nearly as much as bastardized “low-fat”</p><p>junk foods. Enter SnackWell’s Fat-Free Devil’s Food Cookie Cakes.</p><p>The packaged-food industry is happy to hop on any bandwagon and sell</p><p>us any kind of junk food we want: low-fat junk, low-carb junk, gluten-free</p><p>organic junk, and even, ironically, processed paleo junk. But low-fat doesn’t</p><p>necessarily mean low-calorie.1369 A systematic comparison of different</p><p>foods and their low-fat versions found that items with reduced-fat claims</p><p>tend to have more sugar.1370 Instead, we can dismount the processed food</p><p>industry’s sugar-fat seesaw by opting for whole, natural foods.</p><p>Researchers have shown that overfeeding people with either fat or sugar</p><p>can cause the same weight gain.1371 The debate is often framed as fat versus</p><p>carbs, but health-wise, the term carbs is practically meaningless, as it could</p><p>refer to black beans or Blow Pops. If, for weight loss, you replace fatty</p><p>foods in people’s diets with sugary foods, nothing happens, but if you</p><p>replace fatty foods with starchy foods, they lose weight.1372 Presumably, this</p><p>is because the researchers started feeding people more real food (as inferred</p><p>by increased fiber intake), rather than just processed foods with either</p><p>added fats or added sugar.</p><p>The Halo Effect</p><p>Akin to the way people evidently tend to start doing more laundry when</p><p>they get energy-efficient washing machines and thereby undercut their</p><p>savings,1373 low-fat claims can lead consumers to eat larger portions and</p><p>take in more calories.1374 When M&M’s candies were labeled as “low-fat,”</p><p>for example, overweight study participants ate 47 percent more of them.1375</p><p>Consumers tend to overgeneralize specific claims and arrive at</p><p>overreaching conclusions. Many people see the words low fat and assume</p><p>that means the product is healthy overall.</p><p>Taken from the social psychology literature, the halo effect theory helps</p><p>explain these types of leaps. Positive personality traits, for example, are</p><p>inexplicably attributed to people who are more physically attractive.1376</p><p>Cereals use this ploy all the time with nutrient-specific claims like “good</p><p>source of vitamin D.” Lucky Charms can produce a positive “health halo”</p><p>impression to distract the purchaser from the incongruity of feeding their</p><p>children multicolored marshmallows for breakfast.</p><p>Deliberately distracting attention away from negative qualities or the</p><p>overall vacuity of nutritional content has a name: nutri-washing.1377</p><p>Ironically, cereal boxes bearing low-calorie claims have been found to have</p><p>more calories on average than those not asserting to be low-calorie, so</p><p>nutrient claims can be misleading even when understood correctly.1378</p><p>Food, not nutrients, is the fundamental unit in nutrition.1379 The source of</p><p>fat is likely more important than the amount of fat. And let’s not forget that</p><p>the healthiest foods don’t have any nutrition labeling on them at all. In the</p><p>grocery store, you’re more likely to see “healthy” claims adorn Apple Jacks</p><p>than apples.1380</p><p>What Do Losers Eat?</p><p>To bolster their position, low-fat diet proponents often point to the National</p><p>Weight Control Registry. The largest study of those who have successfully</p><p>lost weight,1381 the registry followed thousands of individuals who on</p><p>average reportedly lost sixty-nine pounds and kept it off for more than six</p><p>years.1382 The hope of the study was to identify behaviors associated with</p><p>the most successful losers. What were their secrets?</p><p>Most reported being physically active (primarily walking)1383 and</p><p>weighing themselves at least a few times a week.1384 In terms of diet, at both</p><p>time of entry into the registry and after ten years of successful weight</p><p>maintenance, they were said to have “low calorie and fat intake.” However,</p><p>only a third of the participants ate what you might consider truly low-fat</p><p>diets (no more than 20 percent of their calories from fat).1385 In general,</p><p>though, they did eat relatively low fat, coming in at 26 percent calories from</p><p>fat1386 compared to the current national average of 34 percent.1387</p><p>Although the average registrant dropped from severely obese (BMI 35)</p><p>to normal weight (BMI 24) and kept off the weight for years, several</p><p>hundred of the participants began adding back some of the weight at</p><p>follow-up. This offered the researchers an opportunity to study the factors</p><p>associated with the flip side of the coin, weight gain, and the same finding</p><p>arose: Those who started gaining back the weight were significantly more</p><p>likely to report an increase in fat intake.1388</p><p>Together, the National Weight Control Registry studies provide</p><p>suggestive evidence that lower-fat diets may help with weight loss and</p><p>maintenance, but because it’s not a random sample, the findings can’t be</p><p>generalized to the entire population.1389 Maybe those on lower-fat diets are</p><p>just more likely to submit their medical records and apply for a spot on the</p><p>registry. You don’t know until you put low-fat diets to the test.</p><p>Is Fat Fattening?</p><p>A review of “low-fat” diets for “long-term” weight loss found they resulted</p><p>in about twelve pounds greater weight loss compared to people’s usual</p><p>diets.1390 Why the quotation marks? The tested diets were rarely low in fat</p><p>in actuality, and just a single year counts as “long-term” in many weight-</p><p>loss research circles.</p><p>A major limitation of such studies is that the control groups often don’t</p><p>receive the same amount of attentiveness as the group given the diet being</p><p>tested.1391 Any intervention that focuses greater attention on food intake and</p><p>dietary instruction, regardless of the specifics, may facilitate weight loss.</p><p>Simply being in an obesity study and knowing you have to go in and get</p><p>weighed regularly can motivate people to watch what they eat and cause</p><p>them to lose weight even if they’re in the control group and not told to do</p><p>anything.</p><p>There have been low-fat studies that weren’t about weight loss at all and</p><p>instead aimed to reduce cancer or cardiovascular disease risk. A</p><p>compilation of thirty-two such randomized controlled trials involving more</p><p>than fifty thousand participants found that dietary fat reduction was</p><p>consistently shown to induce body fat reduction even when that wasn’t the</p><p>intention of the intervention.1392 That’s more promising, but there were often</p><p>other lifestyle changes as well, such as exercising or quitting smoking, so</p><p>you can’t separate out the effects of the dietary component.1393 What’s more,</p><p>at least five long-term weight-loss trials failed to show low-fat diets offer</p><p>the same or superior weight loss compared to other diets,1394 adding to the</p><p>debate. But what were these researchers considering “low-fat”?</p><p>A Big Fat Low-Fat Fail?</p><p>To define low fat, you first need to figure out what a normal-fat diet is. Not</p><p>surprisingly, the “normal” intake of dietary fat varies widely by cultural</p><p>cuisine around the world, from 6 percent of calories on the traditional</p><p>Okinawan diet1395 to 66 percent among indigenous Arctic people.1396 But</p><p>what’s normal for us as a species?</p><p>For millions of years, we may have</p><p>evolved getting approximately 10</p><p>percent of our calories from fat.1397 There was no butter or oil, nuts were</p><p>trapped inside hard shells, and animals hadn’t yet been bred to be extra</p><p>juicy. The flesh of some wild game, like moose and elk, is less than 2</p><p>percent fat by weight and less than 15 percent calories from fat.1398 Even the</p><p>“lean” ground beef of today can have nearly half of its calories from fat.1399</p><p>What about “extra lean”? That comes in at 28 percent fat calories,1400 which</p><p>is about double that of the extra, extra, extra lean meat of many wild</p><p>animals eaten by our ancestors.</p><p>Some low-fat proponents have used our evolutionary legacy to support</p><p>their case. After all, the argument goes, what’s the ideal fuel for a motor?</p><p>The fuel it was designed and built for.1401 Our metabolic physiology was</p><p>essentially genetically programmed by our ancestral fat intake, but just</p><p>because 10 percent fat may be normal doesn’t mean it’s best. Natural</p><p>selection is more about getting us to reproductive age intact than it is about</p><p>optimal health and longevity. So while we may not be able to use our</p><p>prehistoric diets to argue for the ideal, we can use them to define normalcy</p><p>for our species.</p><p>It’s been argued that for about 99.8 percent of our time on Earth, it was</p><p>virtually impossible for us to regularly consume more than 15 percent of</p><p>calories as fat.1402 If it’s the case that 10 percent is a normal fat intake for</p><p>humans, less than 10 percent could be defined as low-fat. Given that</p><p>context, let’s review the five studies I could find that purported to show</p><p>“low-fat” diets failed.</p><p>One study published in The New England Journal of Medicine claimed</p><p>to put people on a low-fat diet, but their fat intakes didn’t budge</p><p>significantly, drifting only from 31 percent fat to 30 percent fat.1403 The</p><p>“low-fat” groups in three other studies also ended up at 30 percent fat, far</p><p>from actually being low in fat.1404,1405,1406 A study in Tehran did claim that a</p><p>30 percent fat group beat out a 20 percent fat group for weight loss, but the</p><p>lower-fat group had zero change in fiber intake and no significant change in</p><p>protein, saturated fat, or cholesterol consumption.1407 To get a bump in fiber-</p><p>depleted carb intake without adding fruits, vegetables, whole grains, or</p><p>beans, or without removing meat and dairy would presumably mean giving</p><p>people the Iranian equivalent of SnackWell’s. Regardless, even 20 percent</p><p>fat may be high by evolutionary standards.</p><p>So if 10 percent of calories from fat is normal for us as a species and less</p><p>than that can be considered to be low-fat, why are these studies of so-called</p><p>low-fat diets allowing double and even triple that? You can’t tell if a low-fat</p><p>diet works unless you test a diet that’s actually low in fat.</p><p>You Can’t Win If You Don’t Play</p><p>If you put people on a specific diet and nothing happens, then either the diet</p><p>didn’t work or the people didn’t follow it. Adherence to prescribed diets in</p><p>weight-loss studies is poor even when researchers provide all the meals1408</p><p>and truly abysmal when the subjects are left to fend for themselves.1409 Just</p><p>as medications never work if you don’t take them, diets don’t work if you</p><p>don’t eat them.</p><p>The accompanying editorial to a meta-analysis of “low-fat” weight-loss</p><p>studies that showed little to no benefit was entitled “Prescribing Low-Fat</p><p>Diets: Useless for Long-Term Weight Loss?”1410—with the key word</p><p>prescribing. One could imagine a similar editorial called “Prescribing</p><p>Smoking Cessation: Useless for Preventing Lung Cancer?” because the</p><p>failure rate of physician advice to quit smoking is 98 percent.1411 It’s not that</p><p>quitting smoking doesn’t help; it’s just that people often don’t comply. If</p><p>smokers are able to stop, they can see dramatic improvement in their health,</p><p>but it may take them an average of thirty attempts to quit before they’re</p><p>successful and stop lighting up.1412 Even with a dismal 2 percent success</p><p>rate, we physicians are still urged to advise our patients to stop smoking</p><p>because we know it works if they actually do it. Is that the same with low-</p><p>fat diets? You don’t know until you put actual low-fat diets to the test.</p><p>In a remarkable study out of Hawaii that I detail further here and here,</p><p>subjects achieved seventeen pounds of weight loss in twenty-one days</p><p>eating unlimited quantities of fruits, vegetables, whole grains, and beans.1413</p><p>That diet was 7 percent fat, similar to the traditional Okinawan diet. But</p><p>what about longer term? Some of the heart disease reversal studies got</p><p>people’s diets down to 10 percent of fat or less, which can lead</p><p>unintentionally to a sixteen-pound weight loss in three months.1414</p><p>In the famous Lifestyle Heart Trial, Dr. Dean Ornish motivated people to</p><p>reduce their fat intakes to 6 percent with a diet centered on whole plant</p><p>foods for a year.1415 The participants were also told to exercise, but they</p><p>failed to become any more significantly active than the control group. Even</p><p>though weight loss wasn’t the intention of the study and people could eat as</p><p>much as they wanted, by the end of the year, those randomized to the low-</p><p>fat lifestyle intervention got a twenty-four-pound weight loss as a side</p><p>benefit to reversing their heart disease. At five years, their fat intakes were</p><p>still low at 9 percent and they had sustained a thirteen-pound weight loss.1416</p><p>The Leaking of Alli’s (Orlistat’s) Spotty</p><p>Record</p><p>Like studies involving changes in glycemic index, low-fat interventions involve myriad</p><p>dietary changes, such as changes in meat, junk food, and fiber content. With so many factors,</p><p>how do you know what role the change in fat itself played? You may remember that in the</p><p>case of the glycemic index, there was a starch- and sugar-blocking drug that could effectively</p><p>change the glycemic index of a meal without actually altering the meal itself, which allows us</p><p>to isolate the effect. Well, there’s a fat-blocking drug too.</p><p>Orlistat inhibits the enzyme in your intestines that digests fat and can effectively block the</p><p>absorption of up to 30 percent of the fat you eat.1417 Researchers were able to track people on</p><p>similar diets, with half on the drug and the other half on a placebo, to see if reducing the</p><p>absorption of fat in our bodies really does lead independently to weight loss. So does it work?</p><p>Yes,1418 but it may result in only about a half pound of weight loss a month.1419 But half a</p><p>pound is still half a pound. Orlistat’s serious potential side effects like severe acute kidney1420</p><p>and liver1421 failure are rare, so why aren’t more people taking the drug?</p><p>As I mentioned before, orlistat—sold as Alli—causes “unpleasant symptoms such as anal</p><p>leakage.”1422 Well, the fat that doesn’t get absorbed has to go somewhere. For the oily</p><p>discharge, the drug company apparently prefers the term fecal spotting over anal leakage,1423</p><p>but soiled clothes by any other name would smell as (not so) sweet.</p><p>The drug company’s website offered some helpful tips, such as “it’s probably a smart idea</p><p>to wear dark pants, and bring a change of clothes with you to work.”1424</p><p>How did this drug even get approved? A Freedom of Information Act inquiry unearthed</p><p>more than a thousand adverse events the drug company effectively hid from regulators.1425</p><p>Ironically, though, the “highly visual side effects” actually may have facilitated weight loss by</p><p>steering users away from fattier foods.1426</p><p>So how many people actually stick with the drug? Those seeking weight loss are often</p><p>willing to go to extremes—even major surgery—to lose weight by any means necessary. But</p><p>crapping your pants at work? The percentage of people still on the drug after two years was</p><p>found to be only 2 percent.1427</p><p>The More the Merrier</p><p>Is it possible to lower fat intake yet still achieve weight loss even when</p><p>there is no restriction on portion sizes, no conscious effort to cut calories,</p><p>and unlimited opportunities to eat? Yes. People lose weight on low-fat diets</p><p>not because they are eating less but because they are eating more. In the</p><p>Hawaii study, the subjects lost</p><p>seventeen pounds in three weeks because</p><p>their caloric intakes dropped 40 percent. If you were to do that with caloric</p><p>restriction, you’d have to cut the amount of food you ate nearly in half, but</p><p>the Hawaiians ate more food—in excess of four pounds of food a day.1428</p><p>Natural, low-fat foods tend to be so calorie dilute—that is, have so few</p><p>calories per bite—that eating the same amount of food inevitably leads to</p><p>fewer calories. The same, of course, cannot be said of fat-free cookies.</p><p>This calorie-density mechanism of low-fat-diet weight loss was</p><p>illustrated by an elegant study from my medical alma mater, Tufts.</p><p>Research subjects were switched from a more conventional diet of 35</p><p>percent calories from fat down to a diet getting only 15 percent of its</p><p>calories from fat, but they were forced to eat so much food that they didn’t</p><p>lose any weight. Their weights were monitored closely, and if they started</p><p>to lose weight, they were made to eat more food. The subjects had to eat</p><p>more than five pounds of food a day to maintain their weights and</p><p>“frequently complained of abdominal fullness.” Then, after five or six</p><p>weeks, they were kept on the same 15 percent fat diet but were allowed to</p><p>eat however much they wanted, the amount of food with which they were</p><p>comfortable. Over the next ten to twelve weeks, they lost an average of</p><p>eight pounds. They weren’t told to purposely lose weight. They just</p><p>couldn’t help it.1429</p><p>Normally on a diet, if quantity limits are suddenly removed, you gain</p><p>weight. But on a low-enough-fat diet, even when most people can eat as</p><p>much as they want, they lose weight. It doesn’t happen for everybody,</p><p>though. One guy in the Tufts study actually gained weight in the free-</p><p>feeding phase, and another, who must have gotten used to eating that much</p><p>more food, stayed the same. But the other twenty-seven out of twenty-nine</p><p>participants lost weight, one as much as twenty-nine pounds, all eating ad</p><p>libitum, which is Latin for at one’s pleasure. That’s where the term ad lib</p><p>comes from. In acting, it means going off script. In nutrition research, it</p><p>means eating without limits on quantity.</p><p>It isn’t hard to imagine how ad libitum diets might be superior for long-</p><p>term weight maintenance. To test this, researchers had people lose twenty-</p><p>eight pounds through a combination of drugs and severe caloric restriction.</p><p>They then randomized the subjects to an ad libitum low-fat diet or a food</p><p>exchange–based calorie-counting system to restrict caloric intake to see</p><p>which group was better able to keep off the weight. One year later, the</p><p>weight loss was three times higher in the ad libitum group, and they were</p><p>about 50 percent more likely to maintain a substantial portion of their initial</p><p>lost weights.1430 In the short term, most people can force themselves to cut</p><p>down on the amount of food they eat, but for lifelong weight loss, eating as</p><p>much as you want may be more sustainable.</p><p>Too Little, Too Late</p><p>Give people all-you-can-eat buffets of lower-fat foods, and they end up</p><p>eating hundreds of fewer calories a day than if the buffets contained similar</p><p>foods containing more fat.1431 Depending on the fat content of the food, this</p><p>can then translate into weight loss (at 15–20 percent fat) or weight gain (at</p><p>45–50 percent fat).1432 Researchers offered people essentially the same</p><p>foods, but with some slight tweaks, such as more or less oil, butterfat, or</p><p>margarine slipped in. The foods evidently looked and tasted about the same,</p><p>so people ate about the same amount and spontaneously lost or gained</p><p>weight depending on the fat content. This is the passive consumption I</p><p>explore here, an artifact of calorie density.1433 It’s not the fat per se but</p><p>rather the consequent increase in calories per mouthful because fat can</p><p>sneak lots of calories into a relatively small space.1434 However, there may</p><p>actually be a difference in the appetite feedback loop between fat calories</p><p>and carb calories.</p><p>If I hooked you up to an IV and, unbeknownst to you, dripped 1,300</p><p>calories of sugar into your veins, studies show your body somehow “tastes”</p><p>how sweet your blood has become, does the math, and turns down your</p><p>appetite so much that you spontaneously eat about 1,100 fewer calories that</p><p>day.1435 That’s a huge drop in intake, but your body sensed all those extra</p><p>calories in your system and made you that much less hungry to compensate.</p><p>Genius!</p><p>But if I repeat the experiment with fat, we get a different result. Have</p><p>1,300 calories of fat secretly infused into your veins, and your body knows</p><p>something is going on but doesn’t quite get the same picture as it did when</p><p>you got those extra calories from sugar. So you only end up compensating</p><p>by eating about 500 fewer calories that day.1436 Your body just doesn’t seem</p><p>to register fat calories as well as sugar calories. You can demonstrate this</p><p>with food too.</p><p>If you give people a breakfast of yogurt with a few hundred extra</p><p>calories of sugar mixed in, they eat significantly less of a meal offered</p><p>ninety minutes later than they do when their morning yogurt doesn’t have</p><p>the added sugar. Not enough to account for all the extra sugar, mind you,</p><p>but at least their bodies are trying to compensate. But when they’re given</p><p>the same number of extra calories in fat rather than sugar, there is no effect</p><p>on subsequent meal intake; in fact, they eat a little more.1437 The fat just</p><p>didn’t seem to induce the same braking effect on their appetites, or at least</p><p>not in time.</p><p>So perhaps our bodies aren’t so smart after all? They can only be as</p><p>smart in the context in which they were designed. Snake a tube down</p><p>someone’s throat and secretly squirt some fat straight into their intestines,</p><p>and their hunger can be slashed abruptly.1438 Our bodies successfully sense</p><p>the fat in our intestines and turn down our appetites. The problem is it</p><p>happens too late. By the time high-fat foods make it through our stomachs</p><p>and hit our intestines, we’re usually already done eating. So what good are</p><p>our bodies’ detection mechanisms? Well, what kinds of high-fat foods were</p><p>around during the millions of years our whole system was first evolving?</p><p>Nuts. How fast can you eat walnuts in a shell? Even with a nutcracker in</p><p>hand, it’s slow going. So, in a natural context, our bodies can pick up on the</p><p>fact we just stumbled on some nuts and make sure we don’t overeat, but by</p><p>the time our bodies sense we just ate that fat-infused yogurt or a donut, it’s</p><p>too late. We’ve already swallowed the last bite.</p><p>Dumping More Calories</p><p>So far, we’ve only talked about the calories-in side of the equation—how</p><p>higher fat intakes can unintentionally lead to higher caloric intakes. When</p><p>you think of calories out, expending energy, you likely think exercise, but</p><p>the majority of the calories most of us burn is just from existing. That’s</p><p>what’s called the resting metabolic rate, how many calories we burn every</p><p>hour just to keep our hearts pumping and everything working. For most</p><p>people, that’s around 65 percent of the calories we burn every day.1439</p><p>Another 25 percent is from movement, and the final 10 percent is the</p><p>thermic effect of food, meaning the calories it takes for us to digest what we</p><p>consume. Interestingly, what we eat not only constitutes calories in but also</p><p>can affect all three of these dimensions of calories out.</p><p>Eat a low-fat diet (11 percent calories from fat), and you burn more</p><p>calories in your sleep than when on a high-fat diet (58 percent).1440 The</p><p>difference could be as much as sixty-five calories a night, though</p><p>measurements in this study were taken during overfeeding, which would be</p><p>expected to exaggerate the effect. People on lower-fat diets may</p><p>inexplicably start to move more too. Those randomized to a 20 percent fat</p><p>diet started exercising more, expending eighty-three more calories a day on</p><p>physical activity, whereas the group randomized to the 40 percent fat group</p><p>started expending fifty-nine fewer calories a day.1441 Between them, that’s a</p><p>difference of about a two-mile walk a day.1442 This may help explain why</p><p>those on</p><p>the higher-fat diet lost significantly more lean body mass, down</p><p>three pounds in six months compared to a gain in lean mass in the lower-fat</p><p>group.1443</p><p>At rest, we burn about one calorie a minute, which is comparable to the</p><p>heat produced by a seventy-five-watt light bulb. After meals, that bulb</p><p>burns a little brighter to handle what we just ate.1444 Fat also appears to be</p><p>absorbed more efficiently from the digestive tract, meaning it takes fewer</p><p>calories to process it.1445 A really low-fat diet (3 percent of calories from</p><p>fat) costs about 65 percent more calories to digest than a high-fat diet (40</p><p>percent fat), so, in effect, you’re doing more work just by eating low-fat,</p><p>though the benefit may only come out to be about forty calories a day.1446</p><p>In addition to the three primary components of calories out, there’s</p><p>actually a fourth component, and it’s much more literal: the calories we</p><p>poop out. Those eating low-fat appear to flush more calories down the</p><p>toilet. Overeating on an 11-percent-calories-from-fat diet led to 620 more</p><p>calories down the toilet every week than a same-calorie diet containing 58</p><p>percent calories from fat.1447 That’s nearly 2,500 fewer calories a month</p><p>available for building up fat. Though calories in is the more important side</p><p>of the equation, all these little benefits on the other side may add up to</p><p>greater weight loss over time.</p><p>The Fat You Eat Is the Fat You Bear</p><p>In the Vermont prison studies I mentioned earlier where lean “volunteers”</p><p>were overfed to study experimental obesity, the researchers made an</p><p>important discovery: They learned how difficult it is to get people to gain</p><p>weight on purpose—unless you feed them lots of fat. To get prisoners to</p><p>gain thirty pounds on a mixed diet, it took about 140,000 excess calories per</p><p>a certain body surface area. To get the same thirty-pound weight gain just</p><p>by adding fat to their diets, all the researchers had to do was feed the</p><p>prisoners as few as 40,000 extra calories.1448 When the extra calories were</p><p>in the form of straight fat, it took as many as 100,000 fewer calories to gain</p><p>the same amount of weight. Why? Isn’t a calorie a calorie? Why are our</p><p>bodies so much more efficient at storing fat calories?</p><p>The reason our bodies so easily store fat as fat is because it’s already fat.</p><p>Our bodies can turn protein or carbs into fat, but it’s costly. To store one</p><p>hundred calories of dietary fat as body fat, it only takes three calories of</p><p>energy, but converting one hundred calories of dietary carbs into fat for</p><p>storage takes twenty-three calories.1449 So, if your body wanted to store the</p><p>fat from one hundred pats of butter, it would have to essentially burn three</p><p>pats to make it happen, so you’d end up only storing ninety-seven pats. But</p><p>in order to store one hundred sugar cubes as fat, the conversion process</p><p>alone would burn up nearly a quarter of them. This is why our bodies would</p><p>rather burn carbs and store fat instead of the other way around. Simply</p><p>stated, fat may be more fattening.1450</p><p>When we eat a meal, most of the fat is deposited directly as fat on our</p><p>bodies, whereas a large proportion of the carbs get stored in our muscles for</p><p>quick energy.1451 A study on children found that a high-fat meal deposited</p><p>nine times more fat onto their bodies than the same number of calories of a</p><p>low-fat meal.1452 Where exactly does the fat go? Researchers at the Mayo</p><p>Clinic tagged the fat in a meal with special isotopes to track its movement</p><p>throughout the body. They had research subjects eat the tagged fat and then,</p><p>twenty-four hours later, brought them into the operating room and took fat</p><p>biopsies from their thighs, belly flab, and deep within their abdomens. Of</p><p>the fat in the meal they could account for, about 45 percent was burned right</p><p>off the bat, but most of the fat consumed was simply directed right into their</p><p>fat stores. The researchers found that about 50 percent went straight into</p><p>belly flab, 40 percent to their thighs, and most of the remaining went into</p><p>visceral fat, the fat that’s buried around our major organs.1453 Under normal</p><p>circumstances, less than 1 percent of ingested carbohydrates suffers the</p><p>same fate based on similar studies of isotope-labeled sugar.1454</p><p>Low-fat proponents often point out this fact, that making significant</p><p>amounts of new fat from scratch from ingested carbs only occurs with</p><p>“massive overfeeding”1455 of, for example, a “diet consisted of candy.”1456 If</p><p>you feed people an extra thousand calories of sugar a day, the equivalent of</p><p>up to eleven bags of cotton candy,1457 they do gain about four pounds in</p><p>three weeks,1458 but most of the extra carb calories end up being burned off</p><p>as excess heat.1459 If, however, you added an extra thousand calories of fat,</p><p>like a stick or so of butter every day or a half cup of oil, most of that would</p><p>be directly socked away and stored for a rainy day.1460</p><p>Under more normal circumstances, even if less than 1 percent of the</p><p>carbs in a meal end up as fat, that doesn’t mean that carbs can’t be fattening.</p><p>Normally, our bodies burn fat around the clock at, interestingly, about the</p><p>rate at which a candle burns. (Candles, after all, used to be made from</p><p>animal fat.1461) Carbohydrates are the body’s preferred fuel, so when we eat</p><p>them, our bodies switch from burning fat to burning carbs, effectively</p><p>snuffing out the candle for a few hours. So, while we can certainly gain</p><p>weight from eating carbs, it’s more from sparing our own fat from being</p><p>used, rather than adding more fat directly.1462</p><p>Is All Fat Just as Fattening?</p><p>If you were surprised to learn that, in some ways, fat calories are handled</p><p>differently by the body from how carbohydrate calories are, you may be</p><p>really surprised by the data suggesting that some types of fat calories are</p><p>more fattening than others. I certainly was. There have long been studies</p><p>linking greater saturated fat intake specifically with greater weight gain,1463</p><p>but I always assumed it was just because it was a marker for poorer diets</p><p>and lifestyles in general. After all, the top five sources of saturated fat in the</p><p>United States are essentially cheese, desserts like cake and ice cream,</p><p>chicken, pork, and then burgers.1464</p><p>Interventional studies started to make things more interesting. If you</p><p>switch people from a 38-percent-calories-from-fat diet down to a 28-</p><p>percent-calories-from-fat diet, they lose body fat. Nothing too surprising</p><p>there. But if you switch people from a 38-percent-fat diet of mostly</p><p>saturated fat to a 38-percent-fat diet of mostly monounsaturated fat, like</p><p>that of a more Mediterranean diet, they also lose body fat.1465 The same</p><p>number of calories and the same amount of fat—but a different type of fat</p><p>—meant a different degree of weight loss.</p><p>One way researchers have switched people from a diet rich in saturated</p><p>fat to a more Mediterranean diet is to swap out some meat and dairy for</p><p>nuts and avocados. In this way, they would be eating the same amount of fat</p><p>and calories, but suddenly, they’d also be eating significantly more fiber.1466</p><p>In that case, when they lose more weight, how do you know it was the</p><p>change in fat quality rather than the change in fiber quantity?</p><p>To determine if there’s really a difference between fats, researchers</p><p>designed a study where people ate essentially the same foods—different</p><p>only by the kind of fat. They baked scones. Half were made with sunflower</p><p>oil, and the other half with butter. The liver fat in the sunflower scone eaters</p><p>went down, while the liver fat in the butter scone eaters went up.1467</p><p>Is it possible it was less unsaturated fat versus saturated fat, and more</p><p>plant fat versus animal fat? Dietary cholesterol may be one of the main</p><p>factors associated with liver injury and the development of nonalcoholic</p><p>fatty liver disease,1468 which helps explain why those who eat even just a</p><p>few eggs a week were found to have more than triple the odds of fatty liver</p><p>disease.1469 So how could you separate out that factor?</p><p>Researchers designed a study where people ate essentially the same</p><p>foods, but,</p><p>this time, different only by saturated versus unsaturated fat.</p><p>Instead of scones, this time they baked muffins. Half were made with</p><p>sunflower oil, and the other half with palm oil, a fat that is saturated, but,</p><p>like all plant fats, free of cholesterol. Not only did the palm oil muffins</p><p>result in significantly greater liver and total body fat, they produced twice</p><p>as much visceral fat, the particularly harmful fat wrapped around our</p><p>internal organs.1470 On the saturated-fat diet, they also gained four times as</p><p>much fat as lean tissue.1471 So saturated plant fats like coconut oil not only</p><p>join animal fats in increasing heart disease risk1472 but may also play a role</p><p>in the obesity epidemic.</p><p>One reason saturated fats may be more fattening is that they appear more</p><p>likely to be stored immediately rather than burned. This was found in</p><p>comparisons to both monounsaturated fats (in a match between olive oil and</p><p>cream)1473 and polyunsaturated fats (in a match between mostly safflower</p><p>oil and lard).1474 Oleic acid, the primary monounsaturated fat found in</p><p>olives, nuts, and avocados, is burned promptly about 20 percent more</p><p>readily than palmitic acid,1475 the predominant saturated fat in the American</p><p>diet, which is sourced mainly from meat and dairy.1476 You can drip palmitic</p><p>acid on muscle cells in a petri dish and openly demonstrate the suppression</p><p>of fat utilization.1477 But this difference is too small to account for the</p><p>pounds of extra weight lost when these fats are switched in randomized</p><p>controlled studies.</p><p>In the five hours following a breakfast with about four teaspoons of olive</p><p>oil, research subjects burned about sixteen grams of fat.1478 In the same five-</p><p>hour period after eating essentially the same breakfast, but with the olive oil</p><p>replaced with butterfat, only about thirteen grams of fat were burned. A</p><p>pound of fat is 454 grams, so even if you burned 3 more grams of fat at</p><p>every single meal, at the end of the month, you might only end up about a</p><p>half pound lighter. But in a study where saturated fat was swapped for the</p><p>same amount of mostly olive oil, people lost five pounds of fat in a</p><p>month.1479 Something else has to be going on.</p><p>Remember that thermic effect of food, the amount of energy spent</p><p>digesting, absorbing, and storing a meal? Well, it apparently costs 28</p><p>percent more calories to process a meal containing walnuts and 23 percent</p><p>more calories to process a meal containing olive oil than it does to process a</p><p>meal with the same number of calories and fat but in the form of cheese and</p><p>butter.1480 That sounds like a lot, but our bodies are so efficient either way</p><p>that it doesn’t add up to much—maybe as few as twenty or so calories a</p><p>day.1481 A similar increase of a few calories a day in resting metabolic rate</p><p>has been noted in a trial comparing hazelnut oil to palm oil,1482 but, again,</p><p>there appears to be a missing piece.</p><p>What About Virgin Coconut Oil?</p><p>Coconut oil, one of the latest internet sensations, is touted as a weight-loss “miracle” that</p><p>“ACTUALLY Burns BELLY Fat!”1483 If rats are given purified, medium-chain fatty acids,</p><p>one component of coconut oil, they end up eating less food1484—but does the same apply to</p><p>people?</p><p>An open-label pilot study was published that suggested coconut oil could facilitate weight</p><p>loss.1485 “Open label”? That just means the participants knew what they were eating. They</p><p>didn’t use any kind of placebo control. In fact, there was no control group at all. We’ve talked</p><p>about the well-recognized effect in dietary studies where just being in a weight-loss study and</p><p>under observation tends to lead to a reduction in caloric intake—because you know the</p><p>researchers are looking over your shoulder and are going to put you on a scale.1486 So you</p><p>can’t tell from that kind of study what role—if any—the coconut oil played.</p><p>Enter a non-open-label study. When researchers pitted virgin coconut oil against a placebo</p><p>control, the coconut oil did worse. Not only was there no difference in fat burning, the study</p><p>subjects ended up hungrier after the coconut oil meal. Coconut oil was less satiating than the</p><p>same number of calories of a control oil.1487 It turns out coconut oil is just as fattening as</p><p>other oils in terms of total, belly, or butt/thigh fat and may have adverse metabolic effects.1488</p><p>Give people two tablespoons of coconut oil a day, and, compared to two tablespoons of</p><p>soybean oil, no significant1489 effect on weight or waistlines was found. What did happen,</p><p>though, was a worsening of insulin resistance in the coconut oil group (despite being</p><p>instructed to increase fruits and vegetables, cut down on sugars and animal fat, and exercise</p><p>three hours a week).1490 Coconut oil hawkers claim coconut oil is special because it contains</p><p>medium-chain triglycerides, but MCTs only make up about 10 percent of the product.1491</p><p>Cholesterol-raising saturated fats like those found in beef tallow make up the bulk of coconut</p><p>oil.1492</p><p>If no benefit to coconut oil for obesity over placebo has ever been demonstrated, how can</p><p>coconut oil proponents get away with saying otherwise? They often cite studies of Pacific</p><p>Islanders who were slimmer eating their more traditional, coconut-based diets than those now</p><p>eating more modernized diets with fewer coconut products.1493 Guess what they were eating</p><p>instead? “The modern dietary pattern [was] primarily characterized by high intake of sausage</p><p>and eggs and processed foods.”1494</p><p>Solving the Mystery of the Missing Calories</p><p>How can people lose five pounds of body fat in a month eating the same</p><p>number of calories? Well, if calories in are the same, then it must be</p><p>calories out. If you remember, there are four main components to calories</p><p>out: resting metabolic rate, physical activity, the thermic effect of food, and</p><p>fecal losses. We already determined the differences in resting metabolic rate</p><p>and the thermic effect are insufficient, and there does not appear to be a</p><p>difference in fecal losses between saturated and unsaturated fats.1495 That</p><p>just leaves one other outlet: exercise.</p><p>How could a different type of fat make people exercise more? Early</p><p>studies offered a clue. Those randomized to meals with fat from olives,</p><p>nuts, and avocados tended to feel significantly “more energetic” than those</p><p>getting the same amount of fat from meat and dairy, suggesting the weight</p><p>loss they experienced could have been “enhanced by subtle, unconscious,</p><p>increases in physical activity.”1496 You don’t know, of course, until you put</p><p>it to the test.</p><p>Twenty-nine people were covertly randomized to one of two diets that</p><p>appeared identical but featured different oil blends, one with palm oil and</p><p>one with hazelnut oil. Same calories, same amount of fat, same diets, but</p><p>the palm oil group was secretly slipped saturated fat in place of</p><p>monounsaturated fat. Researchers then attached activity monitors on all the</p><p>subjects to objectively measure how much they were moving. The study</p><p>found that 90 percent of the subjects inexplicably ramped up their exercise</p><p>when they were unwittingly eating the low-saturated-fat diet, increasing</p><p>their activity levels 12–15 percent on average. The researchers concluded</p><p>that a high intake of saturated fat “might dampen motivation for physical</p><p>activity.”1497</p><p>FOOD FOR THOUGHT</p><p>The take-home message is to cut down on fatty meats and dairy, fried foods, greasy snacks</p><p>like corn chips, and added oils.</p><p>At first I was skeptical of oil-free cooking. So many of the dishes I made growing up</p><p>started with sautéing garlic and onions, and how could you possible bake without fat?</p><p>I was delighted to discover that cooking without oil is surprisingly easy. To keep foods</p><p>from sticking in the pan, you can sauté in wine, sherry, broth, vinegar, or just plain water.</p><p>The trick is to just use a little liquid at a time. I use dried mushrooms a lot and always make</p><p>it a habit to save the soaking liquid. I find porcini mushrooms produce an especially rich,</p><p>dark, savory broth that’s perfect for my garlic and onions, and the added umami flavor makes</p><p>it even easier to</p><p>leave the salt out completely.</p><p>For baking, I’ve successfully substituted a variety of healthy whole foods in place of oil.</p><p>Ground flaxseeds blended with water, applesauce, mashed bananas or avocado, soaked prune</p><p>purée, and even canned pumpkin can provide a similar moistness. Vegetables roast just fine</p><p>without added oil. I use a silicone baking sheet, but I hear parchment paper works as well.</p><p>That’s how I make my purple sweet potato fries. I spritz the wedges in apple cider or malt</p><p>vinegar and dredge in coarse blue cornmeal seasoned with sage and smoked paprika. Now</p><p>I’m getting hungry!</p><p>LOW IN ADDED SUGAR</p><p>Sugar Daddy</p><p>A founding member of Harvard’s nutrition department recalled that the</p><p>“meat, milk and egg producers were very upset”1498 by the original Dietary</p><p>Goals for the United States—and they weren’t the only ones. The Dietary</p><p>Goals encapsulate healthy eating advice from the federal government, and</p><p>they named names when it came to foods Americans should cut down on.</p><p>The president of the National Cattlemen’s Beef Association explained that</p><p>his industry “reacted rather violently” because “if these ‘Dietary Goals’ are</p><p>moved forward and promoted in the present form … entire sectors of the</p><p>food industry—meat, dairy, sugar, and others—may be so severely</p><p>damaged that … recovery may be out of reach.”1499</p><p>Critics suggested the adoption of the Dietary Goals would be costly for</p><p>taxpayers too. Because of more expensive groceries? No. Because “health</p><p>care expenditures increase if the lifespan is prolonged.” It’s like when</p><p>people quit smoking: “The increase in the expected lifespan would</p><p>simultaneously increase the cost of care of old people.”1500 In other words, if</p><p>people eat more healthfully and stop smoking, there may be more seniors,</p><p>some of whom might need our care.</p><p>The president of the International Sugar Research Foundation called the</p><p>report “unfortunate and ill-advised” and evidently part of an “emotional</p><p>anti-sucrose [anti-table-sugar] tidal wave.” As immortalized in the official</p><p>record, he said: “Simply stated, people like sweet things, and apparently the</p><p>[Senate] Committee believes that people should be deprived of what they</p><p>like. There is a puritanical streak in certain Americans that leads them to</p><p>become ‘do-gooders.’”1501</p><p>By the time the World Health Organization (WHO) attempted to release</p><p>a similar report decades later, Big Sugar had graduated from name-calling</p><p>to flexing its political muscle. The WHO report, entitled Diet, Nutrition and</p><p>the Prevention of Chronic Disease, contained six fateful words: “limit the</p><p>intake of free sugars” (meaning added sugars). Within days, the sugar</p><p>industry led a vicious attack, culminating in a threat to get Congress to</p><p>withdraw U.S. funding to the World Health Organization entirely1502—all</p><p>because of those six words.</p><p>The threat from the sugar industry was described by WHO insiders as</p><p>worse than any pressure they had ever gotten from the tobacco lobby.1503 As</p><p>revealed in an internal memo, the U.S. government apparently had a list of</p><p>demands from Big Sugar that included the removal of all references to the</p><p>science that WHO experts had compiled on the matter, as well as the call</p><p>for the “deletion of all references to fat, oils, sugar and salt.”1504 In the</p><p>United States, the food industry, like Big Tobacco before it, has had a</p><p>corrosive effect on global public health efforts. When asked why Michelle</p><p>Obama’s childhood obesity programs in the United States should not be</p><p>modeled around the world, a U.S. official responded that they might harm</p><p>American exports.1505</p><p>Sugarcoated Science</p><p>At least a dozen interventional studies document adverse metabolic effects</p><p>of consuming added sugars, though this may be due largely to the</p><p>accompanying weight gain spurred by sugar consumption.1506 This has led</p><p>sugar industry spokespersons, like the head of the World Sugar Research</p><p>Organisation, to say things like “overconsumption of anything is harmful,</p><p>including of water and air.”1507 Yes, he compared the overconsumption of</p><p>sugar to breathing too much.</p><p>This is a throwback to the well-worn tobacco industry script: They’re</p><p>simply providing choices; they don’t condone the overuse of their products;</p><p>and, if people fall ill after consuming it, the victims can only blame</p><p>themselves.1508 The reason this is disingenuous, of course, is that the</p><p>tobacco industry works day and night to make their products as addictive as</p><p>possible, just as the manufacturers of ultraprocessed foods like sugary</p><p>breakfast cereals engineer their products to be as hyperpalatable as possible</p><p>to maximize consumption.1509</p><p>Why won’t cereal manufacturers reduce the amount of sugar in their</p><p>products? A number of explanations have been offered, such as “a product</p><p>with semi-addictive properties may be a safe way to ensure long-term</p><p>revenues.… Another possibility is that selling cereals high in sugar is a</p><p>smart technique to sell expansively a cheap commodity product—sugar.”1510</p><p>Ultraprocessed foods like breakfast cereals1511 tend to have the highest profit</p><p>margins.1512 Remarkably, the cost of packaging may outweigh the cost of</p><p>ingredients in a cereal box by more than ten to one.1513</p><p>Denying evidence that sugars are harmful to health seems always to have</p><p>been at the heart of the sugar industry’s defense.1514 When the evidence is</p><p>undeniable, though—like the link between sugar and cavities1515—the</p><p>industry switches from denial to deflection, such as trying to refocus</p><p>attention away from restricting intake to finding a vaccine against tooth</p><p>decay. We seem to have reached a similar point with obesity, as the Sugar</p><p>Bureau again dodges denial and rushes to deflect. It commissioned research</p><p>suggesting losing weight was useless for extending life among “healthy”</p><p>obese individuals1516—a stance strongly contradicted by hundreds of studies</p><p>across four continents involving more than ten million participants.1517</p><p>The Bitter with the Sweet</p><p>The obesity epidemic may just be the tip of the iceberg in terms of excess</p><p>body fat.1518 As I noted in the Causes section, more than 90 percent of adults</p><p>and greater than two-thirds of the children in the United States are</p><p>estimated to be “overfat”—that is, having excess body fat sufficient to</p><p>impair health. This can occur even in people of normal weight (often due to</p><p>excess abdominal fat). Added sugars have been blamed in part for this</p><p>overfat epidemic.1519</p><p>A century ago, sugar was heralded as one of the cheapest sources of</p><p>calories in the diet.1520 Just ten cents’ worth of sugar could furnish</p><p>thousands of calories. Sugar pushers bristled at the term empty calories,1521</p><p>asserting that the calories in sugar were “not empty but full of energy”—in</p><p>other words, full of calories, of which we now get too many. The excess</p><p>body weight of the U.S. population corresponds to about 350–500 excess</p><p>daily calories on average,1522 which just so happens to be how many</p><p>calories, on average, Americans failing to stay under the suggested sugar</p><p>limits of the U.S. Dietary Guidelines get in added sugars every day.1523</p><p>Maybe that’s a good place to start cutting calories?</p><p>Even the most die-hard sugar defenders—researchers who rely in part on</p><p>sugary food and beverage industry funding for their livelihoods—agree that</p><p>not only is it considered indisputable that sugars contribute to obesity but</p><p>that it is “also undisputable that sugar reduction … should be part of any</p><p>weight loss program.”1524 And that came from someone who was reportedly</p><p>paid $40,000 a month by the high-fructose corn syrup industry on top of the</p><p>$10 million it paid for his research.1525 Of all sources of calories to limit, a</p><p>“reduction in consumption of added sugars should head the list because</p><p>they provide no essential nutrients,”1526 said researchers funded by the Dr</p><p>Pepper Snapple Group and the Coca-Cola Company, including Richard</p><p>Kahn, infamous for signing a million-dollar sponsorship deal with the</p><p>world’s largest candy company when he was chief science officer at the</p><p>American Diabetes Association.</p><p>Not surprisingly, randomized controlled</p><p>trials show that increasing sugar</p><p>intake increases caloric intake,1527 which leads to body weight gain in</p><p>adults, while sugar reduction leads to body weight loss in children.1528 When</p><p>researchers randomized individuals to either increase or decrease their</p><p>intakes of table sugar, the added-sugar group gained about three and a half</p><p>pounds over ten weeks, whereas the reduced-sugar group lost about two and</p><p>a half pounds.1529 A systematic review and meta-analysis of all such ad</p><p>libitum diet studies—that is, real-life studies where sugar levels are changed</p><p>but people can otherwise eat whatever they want—found that reduced</p><p>intake of dietary sugars resulted in a decrease in body weight, whereas</p><p>increased sugar intake resulted in a comparable increase in weight. The</p><p>researchers concluded that “considering the rapid weight gain that occurs</p><p>after an increased intake of sugars,” it seems reasonable to advise people to</p><p>cut down.1530</p><p>Findings from observational studies have been more ambiguous, though,</p><p>with an association found between obesity and sweetened beverage intake,</p><p>but failing to show consistent correlations with sugary foods.1531 Most such</p><p>studies rely on self-reported data, however, and obese people tend to</p><p>underreport consumption of sugar-rich foods, fudging their data, if you will.</p><p>Researchers can, however, measure trace sucrose levels in the urine to get</p><p>an objective measure of actual sugar intake while excluding contributions</p><p>from other sweeteners, such as high-fructose corn syrup. Using this method,</p><p>researchers discovered that sugar intake is indeed not only associated with</p><p>greater odds of obesity and greater waist size in snapshot-in-time cross-</p><p>sectional studies but also in a prospective cohort study over time.1532 Using</p><p>urinary sucrose as the measure of sucrose intake, those in the highest versus</p><p>the lowest fifth for table sugar intake had more than 50 percent greater odds</p><p>of being overweight or obese.1533</p><p>Not Sweet Nothings</p><p>On April Fools’ Day 1998, the FDA announced its approval of the artificial sweetener</p><p>sucralose,1534 sold as Splenda, aka 1,6-dichloro-1,6-dideoxy-β-D-fructofuranosyl-4-chloro-4-</p><p>deoxy-α-D-galactopyranoside.1535 Despite its scary-sounding chemical name, the worst thing</p><p>about it seemed to be that it was a rare migraine trigger in susceptible individuals,1536 to</p><p>which the manufacturer of sucralose responded that you have to weigh whatever risk there</p><p>may be against the “broader benefits,” such as “helping to mitigate the health risks associated</p><p>with the national epidemic of obesity.”1537</p><p>How’s that going?</p><p>Large-scale population studies have found that the consumption of artificial sweeteners,</p><p>particularly in diet sodas, is associated with increased weight gain and abdominal fat over</p><p>time.1538 Now, the obvious explanation for this finding would be reverse causation: Instead of</p><p>drinking more diet soda leading to obesity, it would make more sense that obesity leads to</p><p>drinking more diet soda. But even when researchers controlled for preexisting differences in</p><p>body fat, they still found evidence of increased obesity risk.1539</p><p>However, not all reviews of the science concluded there was a link between artificial</p><p>sweeteners and weight gain. Can you guess which ones? An analysis of industry bias found</p><p>that reviews funded by the food industry were seventeen times less likely to suggest</p><p>unfavorable effects, and in nearly half of the sponsored reviews, the authors failed to even</p><p>disclose their conflicts of interest.1540 That’s even worse than the sugar industry, whose</p><p>studies were “only” five times as likely to question the link between sugar-sweetened</p><p>beverages and obesity.1541 You don’t really know, though, until you put them to the test.</p><p>Ironically, many of the interventional studies on artificial sweeteners and weight gain were</p><p>executed by animal agribusiness, feeding them to farm animals to fatten them faster.1542 (Is</p><p>there anything they won’t feed to chickens?) Animal agriculture has been feeding artificial</p><p>sweeteners to farm animals since the 1950s,1543 boasting their addition “increases … body</p><p>weight gain and … optimizes return on investment.”1544 What about in people?</p><p>If you give obese individuals the amount of sucralose found in a can of diet soda, for</p><p>example, they get significantly higher blood sugar and insulin spikes in response to a sugar</p><p>challenge, suggesting sucralose is not just an inert substance.1545 The Splenda company</p><p>emphasizes that sucralose is hardly even absorbed into the body and ends up in the colon to be</p><p>eliminated.1546 Therein may lie the problem.1547 The adverse metabolic effects of artificial</p><p>sweeteners correlate with “pronounced” changes in the microbiome that occur within a week</p><p>of daily consumption.1548</p><p>The good news is that after stopping artificial sweeteners, your original balance of gut</p><p>bacteria can be restored within a matter of weeks.1549 The problem is that we may be exposed</p><p>without even knowing it. Nearly half of study participants randomized to avoid sucralose, for</p><p>example, still turned up positive, thought to be due to exposure from nondietary sources, such</p><p>as toothpaste and mouthwash.1550</p><p>Another way artificial sweeteners can lead to metabolic disturbance is via the disconnect</p><p>that develops between the amount of sweetness the brain tastes on the tongue and how much</p><p>blood sugar actually ends up reaching the brain. Your brain may end up feeling cheated by the</p><p>artificial sweeteners, figuring you have to consume more and more sweetness in order to get</p><p>enough calories.1551 For example, researchers slipped people either Sprite, Sprite Zero (a no-</p><p>calorie, artificially sweetened Sprite), or unsweetened, carbonated lemon-lime water, and then,</p><p>later on, offered them a choice: They could have M&M’s, spring water, or sugar-free gum.</p><p>Guess who picked the M&M’s? Those who drank the artificially sweetened soda were nearly</p><p>three times more likely to take the candy than either those who had consumed the sugar-</p><p>sweetened soda or the unsweetened drink.1552 So it wasn’t a matter of sweet versus nonsweet</p><p>or even calories versus no calories. There appeared to be something about noncaloric</p><p>sweeteners that tricks the brain into wanting more junk.</p><p>The same researchers performed another study in which everyone was given Oreos and</p><p>then asked how satisfied the cookies made them feel. Again, those who had drunk the</p><p>artificially sweetened Sprite Zero reported feeling less satisfied after eating the Oreos than</p><p>either the subjects who had had normal Sprite or sparkling water. These results are consistent</p><p>with brain imaging studies demonstrating that regular consumption of artificial sweeteners can</p><p>alter the reward pathways responsible for the pleasurable response to food.1553</p><p>What about the natural, plant-based sweeteners derived from stevia and monk fruit?</p><p>Researchers randomized people to drink a beverage sweetened with sugar, aspartame, monk</p><p>fruit, or stevia. Blood sugars were measured over twenty-four hours, and surprisingly, there</p><p>was no significant difference found among any of the four groups.1554</p><p>Wait a second. The sugar group was given sixteen spoonfuls of sugar, the amount in a</p><p>twenty-ounce bottle of Coke, so the other three groups consumed sixteen fewer spoonfuls of</p><p>sugar—yet all four groups still had the same average blood sugars? How is that possible?</p><p>Table sugar causes a big blood sugar spike. Drink that bottle of sugar water with its twenty</p><p>sugar cubes’ worth of sugar, and your blood sugars jump forty points over the next hour. In</p><p>contrast, after drinking a beverage sweetened with aspartame, monk fruit, or stevia, nothing</p><p>happens to blood sugars, which is what we would expect. These are noncaloric sweeteners.</p><p>Since they have no calories, isn’t it just like drinking water? How could our daily blood sugar</p><p>values average out the same? The only way that could happen is if the noncalorie sweeteners</p><p>somehow made our blood sugar spikes worse later in the day—and that’s exactly what</p><p>happened. In the group who drank the aspartame-sweetened beverage,</p><p>have died out, while those who gorged themselves could have</p><p>selectively lived long enough to pass along a genetic predisposition to eat</p><p>and store more calories. That may be how we evolved into such voracious,</p><p>calorie-conserving machines. Now that we’re no longer in such lean times,</p><p>though, we’re no longer so lean.</p><p>What I just described is the “thrifty gene” concept,75 the proposal that</p><p>obesity is the result of a mismatch between the modern environment and the</p><p>environment in which we evolved.76 It’s as if we’re now polar bears in a</p><p>jungle; fur and fat may provide an edge up in the Arctic but would be</p><p>decidedly disadvantageous in the Amazon.77 Similarly, a propensity to pack</p><p>on the pounds may have been a plus in prehistoric times but can turn into a</p><p>liability when our scarcity-sculpted biology is plopped down into the land</p><p>of plenty.</p><p>So the prime cause for the obesity epidemic is neither gluttony nor sloth.</p><p>Obesity may simply be a normal response to an abnormal environment.78</p><p>Much of our physiology is finely tuned to stay within a narrow range of</p><p>upper and lower limits. If we get too hot, we sweat; if we get too cold, we</p><p>shiver. Our bodies have mechanisms to keep us in balance. In contrast, our</p><p>bodies have had little reason to develop an upper limit to the accumulation</p><p>of body fat.79 In the beginning, there may have been evolutionary pressures</p><p>to keep lithe and nimble in the face of predation, but thanks in part to</p><p>weapons and fire, we haven’t had to outrun as many saber-toothed tigers</p><p>over the last two million years or so.80 This may have left our genes with the</p><p>one-sided selection pressures to binge on every morsel in sight and</p><p>stockpile as many calories onto our bodies as possible.81</p><p>What was once adaptive is now a problem, or at least so says the thrifty</p><p>gene hypothesis that originated more than a half century ago.82 The theory</p><p>has since been refined and updated, but the basic premise remains largely</p><p>accepted by the scientific community,83 and the implications are profound.</p><p>In 2013, the American Medical Association voted to classify obesity as a</p><p>disease84 against the advice of its own Council on Science and Public</p><p>Health.85 Not that it necessarily matters what we call it—a rose by any other</p><p>name would cause just as much diabetes—but disease implies dysfunction.</p><p>Bariatric drugs and surgery are not fixing some physiological malfunction.</p><p>Our bodies are just doing what they were designed to do in the face of</p><p>excess calories.86 Rather than some sort of disorder, weight gain may be</p><p>largely a normal response, by normal people, to an abnormal situation.87</p><p>And with more than 70 percent of Americans now overweight,88 it’s</p><p>literally normal.</p><p>Won’t Work for Food</p><p>The traditional medical view on obesity, as summed up nearly a century</p><p>ago: “All obese persons are alike in one fundamental respect—they literally</p><p>overeat.”89 While this may be true in a technical sense, it is in reference to</p><p>overeating calories, not food. Our primitive urge to overindulge is selective.</p><p>People don’t tend to lust for lettuce. We have a natural, inborn preference</p><p>for sweet, starchy, fatty foods, because that’s where the calories are</p><p>concentrated.</p><p>Think about hunting and gathering efficiency. We used to have to work</p><p>hard for our food. Prehistorically, it wouldn’t have made sense to spend all</p><p>day collecting types of food that, on average, don’t provide at least a day’s</p><p>worth of calories. You would have been better off staying back at the cave.</p><p>So we evolved to crave foods with the biggest caloric bang for their buck.90</p><p>If you were able to steadily forage a pound of food an hour and it had</p><p>250 calories per pound, it might take you ten hours just to break even on</p><p>your calories for the day. But if you were gathering something with 500</p><p>calories a pound, you could be done foraging in five hours and spend the</p><p>next five focusing on your wall paintings. So the greater the energy density,</p><p>the more calories per pound, the more efficient the foraging. We developed</p><p>an acute ability to discriminate foods based on calorie density and</p><p>instinctively desire the densest.91</p><p>If you study the fruit and vegetable preferences of four- and five-year-</p><p>old children, what they like correlates with calorie density. They prefer</p><p>bananas over berries and carrots over cucumbers. Isn’t that just a preference</p><p>for sweetness? No, they also prefer potatoes over peaches and green beans</p><p>over melon,92 just like monkeys prefer avocados over bananas.93 We appear</p><p>to have an inborn drive to maximize calories per mouthful.</p><p>The researchers in the studies of children only tested whole fruits and</p><p>vegetables, so all the foods naturally had fewer than five hundred calories</p><p>per pound, with bananas topping the chart at about four hundred. Something</p><p>funny happens when you start going much above that: We lose our ability to</p><p>differentiate between which foods have the highest caloric density. Over a</p><p>natural range of calorie densities, we have an uncanny aptitude to pick out</p><p>the subtle distinctions. However, once you start heading toward chocolate,</p><p>cheese, and bacon territory, which can reach thousands of calories per</p><p>pound, our perceptions become relatively numb to the differences. No</p><p>wonder, since these foods were unknown to our prehistoric brains. Aberrant</p><p>behavior explained by an evolutionary mismatch,94 like sea turtle hatchlings</p><p>crawling in the wrong direction toward artificial light rather than the moon</p><p>and never reaching the ocean, or dodo birds failing to evolve a fear</p><p>response because they had no natural predators—and we all know how that</p><p>turned out.</p><p>Full of CRAP</p><p>The food industry exploits our innate biological vulnerabilities by stripping</p><p>down crops into almost pure calories—straight sugar, oil (which is pretty</p><p>much pure fat), and white flour (which is mostly refined starch). First, they</p><p>remove the fiber, because it effectively has zero calories. Run brown rice</p><p>through a mill to make it white, and you lose about two-thirds of the fiber.</p><p>Turn whole-wheat flour into white flour and lose 75 percent of the fiber. Or</p><p>you can run crops through animals (to make meat, dairy, and eggs) and</p><p>remove 100 percent of the fiber.95 What you’re left with is CRAP, an</p><p>acronym conceived by one of my favorite dietitians, Jeff Novick, for</p><p>calorie-rich and processed foods.96</p><p>Calories are condensed in the same way plants are turned into addictive</p><p>drugs like opioids and cocaine: concentration, crystallization, distillation,</p><p>and extraction.97 They even appear to activate the same reward pathways in</p><p>the brain.98 Put people with “food addiction” in an MRI scanner and show</p><p>them a picture of a chocolate milkshake, and the areas that light up in their</p><p>brains are the same99 as when cocaine addicts are shown a video of smoking</p><p>crack100 or when alcoholics are given a whiff of whiskey.101</p><p>Food addiction is a misnomer. People don’t suffer out-of-control eating</p><p>behaviors to food in general. We don’t tend to compulsively crave cabbage.</p><p>But milkshakes are packed with sugar and fat, two of the signals to our</p><p>brains for calorie density. When people are asked to rate different foods in</p><p>terms of cravings and loss of control, most incriminated was a load of</p><p>CRAP—highly processed foods like donuts, along with cheese and meat.102</p><p>Those foods least related to problematic eating behaviors? Fruits and</p><p>vegetables. Calorie density may be the reason people don’t get up in the</p><p>middle of the night and binge on broccoli.</p><p>Animals don’t tend to get fat eating the foods they were designed to eat.</p><p>There is a confirmed report of free-living primates becoming obese, but that</p><p>was a troop of baboons who evidently stumbled across some dumpsters at a</p><p>tourist lodge. The “garbage-feeding animals” weighed 50 percent more than</p><p>their wild-feeding counterparts.103 Sadly, we, too, can suffer the same</p><p>mismatched fate and become obese by eating garbage. For millions of years</p><p>before we learned how to hunt, our biology evolved largely on leaves, roots,</p><p>shoots, fruits, and nuts.104 Ironically, even the creationists agree that we</p><p>even though their blood</p><p>sugars didn’t rise at the time, they shot up higher an hour later in response to lunch, as if they</p><p>had just consumed a bottle of soda.1555</p><p>That was for an artificial sweetener, though. What about the natural sweeteners, stevia and</p><p>monk fruit? The same thing happened. The same exaggerated blood sugar spike to a regular</p><p>meal occurred an hour later. So that’s how it all equals out in terms of average blood sugars</p><p>even though, in these three noncaloric sweetener groups, the subjects took in sixteen fewer</p><p>spoonfuls of sugar. This is at least partly because they ate more. After drinking a Diet Coke,</p><p>you’re more likely to eat more at your next meal than you would if you had drunk a regular</p><p>Coke. In fact, you’d eat so much more that the calories “saved” from replacing sugar with</p><p>noncaloric sweeteners would be fully compensated at subsequent meals, resulting in no</p><p>difference in total daily caloric intake. It’s as if the zero-calorie sweetener groups—whether</p><p>sweetened artificially or naturally—had chugged a bottle of sugary soda. So, when it comes to</p><p>caloric intake, blood sugars, or insulin spikes, all the other sweeteners appeared just as bad as</p><p>straight sugar.1556</p><p>Do we have direct evidence that diet beverages can adversely impact body weight? Yes. If</p><p>you swap out diet beverages for water, there theoretically should be no difference in weight</p><p>control since they both provide zero calories, right? Well, when researchers put it to the test,</p><p>overweight and obese individuals on a diet randomized to replace diet beverages with water</p><p>lost significantly more weight, about 15 percent more over six months.1557,1558</p><p>The researchers who demonstrated artificial sweeteners can disrupt our microbiomes and</p><p>metabolisms recognized the irony of their findings. Though these food additives were</p><p>introduced to reduce caloric intake and counter the obesity epidemic, they noted their findings</p><p>suggest artificial sweeteners may have instead “directly contributed to enhancing the exact</p><p>epidemic that they themselves were intended to fight.”1559</p><p>Long in the (Sweet) Tooth</p><p>The industry is quick to point out that a calorie is a calorie, and an excess of</p><p>calories from Coca-Cola would cause no more weight gain than the same</p><p>excess of calories from carrots.1560 While this may be true in a tightly</p><p>controlled laboratory setting,1561 it doesn’t take into account the appetite-</p><p>enhancing effects of sugar.1562 Remember the experiment where children</p><p>were alternately offered high- or lower-sugar cereals? As I mentioned here,</p><p>surprisingly, Cheerios has a similar number of calories to Froot Loops (104</p><p>calories per cup1563 versus 110,1564 respectively). Had the kids eaten more</p><p>Cheerios than Froot Loops, they could have gotten more calories, but the</p><p>opposite happened. On average, the children poured and ate 77 percent</p><p>more of the sugary cereals. So even with comparable calorie counts per</p><p>serving, sugary cereals may end up nearly doubling caloric intake.1565</p><p>Millions of years of evolution have genetically hardwired us with both</p><p>an innate liking of the sweet taste of ripe fruit 1566 and a sugar-induced</p><p>subversion of some of our satiety mechanisms.1567 When we eat, desire for</p><p>salty, fatty, and savory tastes diminishes as we slake our hunger, whereas</p><p>our desire for sweetness is maintained.1568 This makes sense. Because fruit</p><p>is sporadic and seasonal, an overfeeding response upon discovering a berry</p><p>bush would have triggered our hunter-gatherer ancestors to eat as much as</p><p>possible to store energy for later.1569 This may explain why we seem to grow</p><p>a “second stomach” when it comes to dessert. Children may be especially</p><p>vulnerable since they have a stronger preference for sweet foods than</p><p>adults,1570 and repeated exposures to sugary foods may accustom young</p><p>children to a lifelong habit of consuming overly sweet foods.1571</p><p>In recent years, much has been learned about the reinforcing effects of</p><p>sugar and how it can promote overeating.1572 Evidence supports the thinking</p><p>that we don’t just overeat sugar because we like its sweet taste.1573 As I note</p><p>in the Low in Addictive Foods section, innovations in brain scanning</p><p>technology have shown that the pleasure-generating reward circuitry in our</p><p>brains overlaps with the neurocircuitry that mediates the addictive</p><p>properties of drugs like alcohol and opioids. Sugar consumption has also</p><p>been shown to inhibit anxiety-induced cortisol (stress hormone) secretion,</p><p>helping to explain why many “comfort foods” are high in sugar and also</p><p>why excessive sugar consumption may be such a difficult habit to break.1574</p><p>How Much Is Too Much?</p><p>At the time of the American Revolution, we consumed about an estimated</p><p>four pounds of sugar per person per year.1575 Now, we may each average</p><p>more than fifty pounds annually.1576 That’s the equivalent of about</p><p>seventeen teaspoons of added sugars every day.</p><p>The excessive consumption of added sugar is a systemic problem that</p><p>extends far beyond just a small group of individuals making poor dietary</p><p>choices.1577 In the United States, individuals in every single age bracket</p><p>exceed the U.S. Dietary Guidelines’ recommended limit of no more than 10</p><p>percent of calories from added sugars. The average American exceeds the</p><p>guideline by more than 30 percent,1578 and adolescents exceed it by 60</p><p>percent.1579</p><p>Though the Sugar Association describes the maximum limit as</p><p>“extremely low,”1580 let’s not forget that there is no dietary requirement for</p><p>added sugars at all.1581 The American Heart Association went further,</p><p>recommending that most American women should get no more than 100</p><p>calories per day from added sugars and most American men no more than</p><p>150.1582 This comes out to be about 6 percent of calories,1583 with</p><p>recommendations for some demographics falling as low as 3 percent.1584</p><p>Currently, approximately nine out of ten Americans are exceeding these</p><p>recommendations.1585</p><p>In 2017, the American Heart Association released its guidelines for</p><p>children, recommending they get no more than 100 calories of added sugars</p><p>per day (and none for those under age two).1586 For a teenager expending</p><p>2,500 calories a day, that represents a limit of fewer than 5 percent of</p><p>calories from added sugars. Sugary breakfast cereals alone violate these</p><p>limits in up to 30 percent of toddlers.1587 An average serving1588 of every</p><p>single one of the top ten breakfast cereals marketed to children would take</p><p>up more than half the daily sugar limit,1589,1590 and there are nearly one</p><p>hundred cereals on the market for which a single serving would push kids</p><p>up and over the limit.1591</p><p>The United States is one of at least sixty-five countries that have</p><p>implemented dietary guidelines or public health policies to curb sugar</p><p>consumption.1592 In the United Kingdom, the Scientific Advisory</p><p>Committee on Nutrition made recommendations to reduce calories from</p><p>added sugars down to 5 percent,1593 consonant with the American Heart</p><p>Association and the latest conditional recommendation from the World</p><p>Health Organization,1594 whose policy-making process is protected from</p><p>industry influence.1595 That means a single can of soda could easily take us</p><p>over the top for the day.1596</p><p>FOOD FOR THOUGHT</p><p>Note that none of these recommendations to cut down on added sugars applies to fruit. As</p><p>you’ll read in the Rich in Fruits and Vegetables section, fruit can actually facilitate weight</p><p>loss. If you randomize people to a diet low in all sugars, even the naturally occurring sugars</p><p>in fruit, they do worse than those randomized to just cut down added sugars. Those who</p><p>retained fruit in their diets lost nearly 50 percent more weight.1597</p><p>For those of you who have a sweet tooth like I do, all hope is not lost. The same palate-</p><p>changing effects on your taste thermostat found after cutting down on salt and fat also work</p><p>with cutting down on sugar. Put people on a sugar-free challenge for two weeks, removing all</p><p>added sugars and artificial sweeteners, and by the end of the trial, up to 95 percent said</p><p>“sweet foods and drinks tasted sweeter</p><p>started out plant-based in Eden’s garden.105 Maybe it would help if we went</p><p>back to the basics and cut the CRAP.</p><p>Toxic Food Environment</p><p>It is hard to eat healthfully against the headwind of such strong evolutionary</p><p>forces. No matter our level of nutrition knowledge, in the face of pepperoni</p><p>pizza, the ancestral heritage baked into our genes screams, Eat it now!106</p><p>Anyone who doubts the power of basic biological drives should see how</p><p>long they can go without blinking or breathing. Any conscious decision to</p><p>hold your breath is soon overcome by the compulsion to breathe. In</p><p>medicine, shortness of breath is sometimes even referred to as air hunger.</p><p>The battle of the bulge is a battle against biology, so obesity is not some</p><p>moral failing. I can’t stress enough that becoming overweight is a normal,</p><p>natural response to the abnormal, unnatural ubiquity of calorie-dense,</p><p>sugary, and fatty foods.</p><p>The sea of excess calories in which we are now floating (and in which</p><p>many of us are now drowning) has been referred to as a “toxic food</p><p>environment.”107 This helps direct focus away from the individual and</p><p>toward societal forces at work, such as the fact that the average child may</p><p>be blasted with ten thousand food commercials a year. Or maybe I should</p><p>say pseudo-food commercials, as 95 percent of the ads were found to be for</p><p>candy, liquid candy (soft drinks), breakfast candy (sugary cereals), and fast</p><p>food.108</p><p>Wait a second. If weight gain is just a natural reaction to the easy</p><p>availability of mountains of cheap, tasty calories, then why isn’t everyone</p><p>fat? Well, in a certain sense, most everyone is. It’s been estimated that more</p><p>than 90 percent of American adults are “overfat,” defined as having excess</p><p>body fat sufficient to impair health.109 This can occur even in normal-weight</p><p>individuals (often due to excess abdominal fat), but even if you just look at</p><p>the numbers on the scale, being overweight has become the norm. If you</p><p>look at the bell curve, more than 70 percent of us are overweight. A little</p><p>less than a third are on one side at normal weight and more than a third are</p><p>on the other side, so overweight they’re obese.110</p><p>But if it really is the food, why doesn’t everyone get fat? That’s like</p><p>asking, “If cigarettes really are to blame, why don’t all smokers get lung</p><p>cancer?” This is where genetic dispositions and other exposures can weigh</p><p>in to tip the scales.111 Different people are born with a different</p><p>susceptibility to cancer, but that doesn’t mean smoking doesn’t play a</p><p>critical role in exploding whatever inherent risk we have—and the same</p><p>goes for obesity and our toxic food environment. We can try to tip the</p><p>scales with smoking cessation and a more healthful diet.</p><p>If you lock up two dozen folks in a research study and feed each the</p><p>exact same number of excess calories, they all gain weight, but some gain</p><p>more than others. In one study, overfeeding the same thousand calories a</p><p>day, six days a week for one hundred days caused weight gains ranging</p><p>from about nine pounds to twenty-nine pounds. Some people are just more</p><p>genetically susceptible. The twenty-four people in the study were twelve</p><p>sets of identical twins, and the variation in weight gain between each of</p><p>them was about a third less than between the unrelated subjects.112 A similar</p><p>study with weight loss from exercise found a similar result.113 So, yes,</p><p>genetics play a role, but that just means some people have to work harder</p><p>than others. Ideally, inheriting a predisposition for extra weight gain</p><p>shouldn’t give reason for resignation but rather motivation to put in the</p><p>extra effort to unseal your fate.</p><p>Fattening Grandchildren from the Womb</p><p>Identical twins don’t just share DNA; they shared a uterus too. Might that also help account</p><p>for some of their metabolic similarities? Fetal overnutrition, evidenced by an abnormally large</p><p>birth weight, seems to be a strong predictor of obesity in childhood and later in life.114 Could</p><p>it be that you are what your mom ate?</p><p>Who do you think most determines the birth weight of a test-tube baby—the donor mom</p><p>who provided all the DNA, or the surrogate mom who provided the intrauterine environment?</p><p>When it was put to the test, the womb won. Incredibly, a baby born to an obese surrogate</p><p>mother with a skinny biological mom may harbor a greater risk of becoming obese than a</p><p>baby from a big biological mom born to a slim surrogate. The researchers concluded that “the</p><p>environment provided by the human mother is more important than her genetic contribution to</p><p>birth weight.”115</p><p>The most compelling data come from comparing obesity rates in siblings born to the same</p><p>mother before and after she had bariatric (weight loss) surgery.116 Compared to their brothers</p><p>and sisters born after the surgery, those born when the mom weighed about one hundred</p><p>pounds more had higher rates of inflammation and metabolic derangements, and, most</p><p>critically, three times the risk of severe obesity (affecting 35 percent of those born before the</p><p>weight loss, compared to 11 percent born after). The researchers concluded that “these data</p><p>emphasize how critical it is to prevent obesity and treat it effectively to prevent further</p><p>transmission to future generations.”117</p><p>But wait. Mom had the same DNA before and after the surgery. She passed down the same</p><p>genes. How could her weight during pregnancy affect the weight destiny of her children any</p><p>differently? We finally figured out the mechanism by which this can happen: epigenetics.</p><p>Epigenetics, which literally means above genetics, layers an extra level of information on</p><p>top of the DNA sequence that can both be affected by our surroundings and potentially passed</p><p>on to our children.118 This is thought to account for the “developmental programming”119</p><p>(also known as metabolic imprinting120) that can occur in the womb depending on the weight</p><p>of the mother, or even the grandmother. Since all the eggs in an infant daughter’s ovaries are</p><p>already preformed before birth,121 a mother’s weight status during pregnancy could</p><p>potentially affect the obesity risk of her grandchildren too.122 Either way, you can imagine</p><p>how this could result in a vicious intergenerational cycle where obesity begets obesity.</p><p>Is there anything we can do about it? Well, prevention may be the key. Given the epigenetic</p><p>influence of maternal weight during pregnancy, a symposium of experts on pediatrics</p><p>concluded that “planning of pregnancy, including prior optimization of maternal weight and</p><p>metabolic condition, offers a safe means to initiate the prevention rather than treatment of</p><p>pediatric obesity.”123 Easier said than done, but overweight moms-to-be may take comfort in</p><p>the fact that even the moms in the study who had given birth to kids with three times lower</p><p>risk of obesity were still, on average, obese themselves,124 suggesting that significant weight</p><p>loss can help even if you’re not able to get down to a normal weight.</p><p>What Happened in the 1970s?</p><p>The rise in the number of calories provided by the U.S. food supply since</p><p>the 1970s is more than sufficient to explain the entire obesity epidemic.125</p><p>Similar spikes in calorie surplus were noted in developed countries around</p><p>the world in parallel with,126 and presumed primarily responsible for,127 the</p><p>expanding waistlines of their populations. By the year 2000, after taking</p><p>exports into account, the United States was producing 3,900 calories a day</p><p>for every man, woman, and child, nearly twice as much as many people</p><p>need.128</p><p>The number of calories in the food supply actually declined over the first</p><p>half of the twentieth century, only starting its upward climb to</p><p>unprecedented heights in the 1970s.129 The drop in the first half of the</p><p>century was attributed to the reduction in hard manual labor. The population</p><p>had decreased energy needs, so they ate decreased energy diets. They didn’t</p><p>need all the extra calories. But then, the so-called energy balance flipping</p><p>point occurred. (Energy balance is the concept of calories in versus calories</p><p>out.) Why did the “move less, stay</p><p>lean” phase that had existed throughout</p><p>most of the century turn into the “eat more, gain weight” phase that plagues</p><p>us to this day?130 What changed to bring about this flipping point?</p><p>What happened in the 1970s was a revolution in the food industry. In the</p><p>1960s, most food was prepared and cooked in the home. The average</p><p>housewife spent hours a day cooking and cleaning up after meals (the</p><p>husband averaged nine minutes).131 But then a profound transformation took</p><p>place. Technological advances in food preservation and packaging enabled</p><p>manufacturers to mass prepare and distribute food for ready consumption.</p><p>The metamorphosis has been compared to what had happened a century</p><p>before in the Industrial Revolution with the mass production and supply of</p><p>manufactured goods. This time, though, it was the mass production and</p><p>supply of food. Using new preservatives, artificial flavors, and techniques</p><p>such as deep freezing and vacuum packing, food companies could take</p><p>advantage of economies of scale132 to mass-produce ready-made, durable,</p><p>palatable edibles that offer an enormous commercial advantage over fresh</p><p>and perishable foods.133 And the packaged food sector is now a</p><p>multitrillion-dollar industry.134</p><p>Think ye of the Twinkie. With enough time and effort, any ambitious</p><p>cook could create cream-filled cakes in their own kitchen, but today they</p><p>are available at every turn for less than a dollar.135 If every time we wanted a</p><p>Twinkie we had to bake it ourselves, we’d probably eat far fewer of them.136</p><p>Consider the humble potato. We’ve long been a nation of potato eaters,</p><p>but they were largely baked or boiled. Anyone who has made fries from</p><p>scratch knows what a pain it is, with all the peeling, cutting, and splattering.</p><p>But with sophisticated machinations of mechanization, french fry</p><p>production became centralized so fries could be shipped at -40°F to any</p><p>fast-food deep-fat fryer or supermarket frozen food section in the country to</p><p>become America’s favorite vegetable. Nearly all the increase in potato</p><p>consumption in recent decades has been in the forms of french fries and</p><p>potato chips.137</p><p>Cigarette production offers a compelling parallel. Before the automated</p><p>rolling machine was invented, cigarettes had to be rolled by hand. It took</p><p>fifty workers to produce the same number of cigarettes a machine could</p><p>make in a single minute. After automation, cigarette prices plunged and</p><p>production leaped into the billions.138 Cigarette smoking went from being</p><p>relatively uncommon to almost everywhere. In the twentieth century, the</p><p>average per capita cigarette consumption rose from 54 cigarettes a year to</p><p>4,345 by the time of the 1964 Surgeon General’s report.139 The average</p><p>American went from smoking about 1 cigarette a week to 70. That’s a half</p><p>pack a day.</p><p>Tobacco itself was just as addictive before and after mass marketing.</p><p>What changed was the much greater opportunity for cheap, easy access.</p><p>French fries have always been tasty, but they went from being rare even in</p><p>restaurants to omnipresent around every corner. You can probably even find</p><p>them next to the gas station where you can get your Twinkies and cigarettes.</p><p>The first Twinkie dates back to 1930, though, and Ore-Ida started selling</p><p>frozen french fries in the 1950s.140 So there has to be more to the story than</p><p>just technological innovation.</p><p>Aiding and Abetting</p><p>The rise in calorie surplus sufficient to explain the obesity epidemic was</p><p>less a change in food quantity than in food quality, with an explosion in</p><p>cheap, high-calorie, low-quality convenience foods. The federal</p><p>government very much played a role in making this happen. U.S. taxpayers</p><p>unwittingly give billions in subsidies to prop up the likes of the sugar</p><p>industry, the corn industry and its high-fructose syrup, and the soybean</p><p>industry, which processes about half of its crop into vegetable oil and the</p><p>other half into cheap animal feed to help make Dollar Menu meat.141 When</p><p>was the last time you sat down to some sorghum? Exactly. Why then do</p><p>taxpayers give nearly a quarter billion dollars a year to the sorghum</p><p>industry?142 It’s almost all fed to livestock.143 We’ve created a pricing</p><p>structure that favors the production of sugars, oils, and animal products.144</p><p>The first farm bill started out as an emergency measure during the Great</p><p>Depression of the 1930s to protect small farmers, but subsequent ones were</p><p>weaponized by Big Ag into cash cows with pork barrel politics.145</p><p>Agricultural policies in the United States and Europe have been deliberately</p><p>designed to lower the costs of basic cash crops like sugar and staples like</p><p>meat, wheat, dairy, and eggs.146 There is a lot of money at stake—and in</p><p>steak. From 1970 to 1994, for example, global beef prices dropped by more</p><p>than 60 percent.147 If it weren’t for taxpayers sweetening the pot with</p><p>billions of dollars a year,148 high-fructose corn syrup would cost the soda</p><p>industry about 10 percent more.149</p><p>Subsidies are one of the reasons chicken is so cheap. After one of the</p><p>farm bills, corn and soy were subsidized below the cost of production for</p><p>cheap animal fodder, effectively handing the poultry and pork industries</p><p>around $10 billion each.150 That’s not chicken feed. Or rather, it is!</p><p>This is changing what we eat. Thanks in part to subsidies, meats, sweets,</p><p>eggs, oils, dairy, and soda were all getting relatively cheaper as the obesity</p><p>epidemic took off (compared to the overall consumer food price index),</p><p>whereas the relative cost of fresh fruits and vegetables doubled.151 This may</p><p>help explain why, during about the same period, the percentage of</p><p>Americans getting five servings of fruits and vegetables a day dropped from</p><p>42 percent to 26 percent.152 Why not subsidize produce instead? Because</p><p>that’s not where the money is.</p><p>Whole foods, or minimally processed foods such as canned beans or</p><p>tomato paste, are what’s referred to in the food business as commodities.</p><p>They have such slim profit margins that they’re sometimes even sold at or</p><p>below cost as “loss leaders” to attract customers in the hopes they’ll also</p><p>buy the “value-added” products,153 the most profitable of which (for</p><p>producers and vendors alike) are the ultraprocessed, fatty, sugary, and salty</p><p>concoctions of artificially flavored, artificially colored, and artificially</p><p>cheap ingredients, thanks to taxpayer subsidies.</p><p>Different foods reap different returns. Measured in profit per square foot</p><p>of supermarket selling space, confectionaries like candy bars consistently</p><p>rank among the most lucrative. Fried snacks like potato chips and corn</p><p>chips are also highly profitable. PepsiCo’s subsidiary Frito-Lay brags that</p><p>while its products represent only about 1 percent of total supermarket sales,</p><p>they may account for more than 10 percent of the operating profits for</p><p>supermarkets and 40 percent of profit growth.154</p><p>It’s no surprise then that the entire system is geared toward garbage. The</p><p>rise in the calorie supply wasn’t just more food but more of a different kind</p><p>of food. More than half of all calories consumed by most adults in the</p><p>United States these days were found to originate from these subsidized</p><p>foods, and we appear to be worse off for it. Those eating the most have</p><p>significantly higher levels of chronic disease risk factors, including elevated</p><p>cholesterol, inflammation, and body weight.155</p><p>There’s a dumb dichotomy about the drivers of the obesity epidemic: Is</p><p>it the sugar or the fat? Both are highly subsidized, and both took off during</p><p>the unfolding epidemic. Along with a significant rise in refined grain</p><p>products, the rise in obesity was accompanied by about a 20 percent</p><p>increase in per capita pounds of added sugars and a 36 percent increase in</p><p>added fats156 (mostly in the form of oil,157 presumably from fried fast food</p><p>and processed junk).158 Both added sugars and added fats now represent</p><p>major sources of calories in the American diet.159</p><p>Quarter Pounder</p><p>In the 1970s, the U.S. government went from just subsidizing some of the</p><p>worst foods to actually paying companies to make more of them. During</p><p>that decade, the farm bills reversed long-standing policies aimed at limiting</p><p>production to protect prices and instead started giving payouts in proportion</p><p>to output.160 Extra calories began pouring into the food supply.</p><p>Then, in 1981, the CEO of General Electric gave a speech that</p><p>effectively launched the “shareholder-value movement,” reorienting the</p><p>primary goal of corporations toward maximizing short-term returns for</p><p>investors.161 This placed extraordinary pressures on food companies from</p><p>Wall Street to post increasing profit growth every quarter to boost their</p><p>share prices. There was already a glut of calories on the market, and now</p><p>they had to sell even more.</p><p>This puts food and beverage CEOs into a near impossible bind. It’s not</p><p>like they’re rubbing their sticky hands together at the thought of luring</p><p>more Hansels and Gretels to their doom in their houses of candy. Food</p><p>giants cannot necessarily do the right thing if they wanted; they are</p><p>beholden to investors. If they stopped marketing to kids or tried to sell</p><p>healthier food or attempted anything that could jeopardize their quarterly</p><p>profit growth, Wall Street could demand a change in management.162</p><p>Healthy eating is bad for business. It’s not some grand conspiracy—it’s not</p><p>even anyone’s fault. It’s just how the system works.</p><p>Marketing Excesses</p><p>Given the constant demands for corporate growth and rapid returns in an</p><p>already oversaturated marketplace, the food industry needed to get people</p><p>to eat more. Like the tobacco industry before it, the food industry turned to</p><p>the ad men—and in a big way.163 Tens of millions of dollars are now spent</p><p>annually advertising a single brand of candy bar.164 McDonald’s alone</p><p>spends billions a year.165 Thus far, the food industry has spent more money</p><p>on advertising than any other sector of the economy.166</p><p>Reagan-era deregulation removed the limits placed on marketing food</p><p>products on television to children.167 In addition to the ten thousand food</p><p>ads children may see on TV a year,168 there is marketing content online, in</p><p>print, at school, on their phones, at the movies, and everywhere in</p><p>between.169 Nearly all of it is for products detrimental to their health.170</p><p>Besides its massive early exposure171 and ubiquity, food marketing has</p><p>become highly sophisticated. With the help of child psychologists,</p><p>companies learn how best to influence children to manipulate their parents.</p><p>Packaging is designed to most effectively attract a child’s attention and then</p><p>placed at their eye level in the store.172 You know those mirrored bubbles in</p><p>the ceilings of supermarkets? They’re not just for shoplifters. Closed-circuit</p><p>cameras and GPS-like devices on shopping carts are used to strategize how</p><p>best to guide shoppers toward the most profitable products.173 Behavioral</p><p>psychology is widely applied to increase impulse buying, and even eye-</p><p>movement tracking technologies are utilized.174</p><p>The unprecedented rise in the power, scope, and sophistication of food</p><p>marketing starting around 1980 aligns well with the blastoff slope of the</p><p>obesity epidemic. Since then, some of the techniques, such as product</p><p>placement, in-school advertising, and event sponsorships, skyrocketed from</p><p>essentially nothing to multibillion-dollar industries. This led at least one</p><p>noted economist to conclude that “the most compelling single interpretation</p><p>of the admittedly incomplete data we have is that the large increase in</p><p>obesity is due to marketing.”175 Innovations in manufacturing and political</p><p>maneuvering led to a food supply bursting at the seams with nearly four</p><p>thousand calories a day for each one of us, but the critical piece may have</p><p>been the advancements in marketing manipulations used to try to peddle</p><p>that surplus into our mouths.176</p><p>Wining and Dining</p><p>The opening words of the National Academy of Medicine’s report on the</p><p>threat posed by food ads: “Marketing works.”177 Yes, there’s a large number</p><p>of well-conducted randomized studies I could share with you to show how</p><p>advertising exposure and other marketing methods can change your eating</p><p>behavior and get you to eat more,178 but what do you need to know beyond</p><p>the fact that the industry spends tens of billions of dollars on it?179 To get</p><p>people to drink its brown sugar water, do you think Coca-Cola would spend</p><p>a penny more than it thought it had to? It’s like when my medical</p><p>colleagues accept invitations to “drug lunches” from pharmaceutical</p><p>representatives and take offense that I would suggest it might affect their</p><p>prescribing practices. Do they really think drug companies are in the</p><p>business of giving away free money for nothing? They wouldn’t do it if it</p><p>didn’t work. There is no free lunch.</p><p>Just to give you a sense of marketing’s insidious nature, let me share an</p><p>interesting piece of research published in Nature, the world’s leading180</p><p>scientific journal. The article titled “In-Store Music Affects Product</p><p>Choice” documented an experiment in which either French accordion or</p><p>German Bierkeller music was played on alternate days in the wine section</p><p>of a grocery store.181 On the days the French music played in the</p><p>background, people were three times more likely to buy French wine, and</p><p>on German music day, shoppers were about three times more likely to buy</p><p>German wine. Despite the dramatic effect—not just a few percent</p><p>difference but a complete threefold reversal—when approached afterward,</p><p>the vast majority of shoppers denied the music had influenced their</p><p>choices.182</p><p>Like a Kid in a Candy Store</p><p>In addition to the $10 billion or so spent on advertising each year, the food industry spends</p><p>around another $20 billion on other forms of marketing, such as trade shows, incentives,</p><p>consumer promotions, and supermarket “slotting fees,”183 which are the purchasing of shelf</p><p>space from grocery stores by food and beverage companies to prominently display their most</p><p>profitable products. The practice is evidently known as cliffing, because companies are forced</p><p>to bid against each other for eye-level shelf placement, with the loser being pushed “over the</p><p>cliff.”184 With slotting fees up to $20,000 per item, per retailer, and per city,185 you can</p><p>imagine what kinds of products get the special treatment. Hint: It ain’t broccoli.</p><p>To get a sense as to what types of products merit prime-shelf real estate, look no further</p><p>than the checkout aisle. “Merchandising the power categories on every lane is critical,” reads</p><p>a trade publication on the “best practices for superior checkout merchandising.” And what are</p><p>the “power categories”? Candy bars and beverages. Evidently, even a 1 percent power</p><p>category boost in sales could earn a store an extra $15,250 a year.186 It’s not that supermarkets</p><p>don’t care about their customers’ health. It’s more that publicly traded companies (like most of</p><p>the leading grocery store chains) are impelled to increase profits above other</p><p>considerations.187</p><p>Driven by Distraction</p><p>We all like to think we make important life decisions, such as what to eat,</p><p>consciously and rationally. If that were the case, though, we wouldn’t be in</p><p>the midst of an obesity epidemic.188 As I explore in the Habit Formation</p><p>section, most of our day-to-day behavior does not appear to be dictated by</p><p>careful, considered deliberations. Rather, we tend to make more automatic,</p><p>impulsive decisions triggered by unconscious cues or habitual patterns,</p><p>especially when we’re tired, stressed, or preoccupied. The unconscious</p><p>parts of our brains are thought to guide human behaviors as much as 95</p><p>percent of the time,189 and this is the arena where marketing manipulations</p><p>do most of their dirty work.</p><p>The parts of our brains that govern conscious awareness may only be</p><p>able to process about fifty bits of information per second, which is roughly</p><p>equivalent to a short tweet. Our entire cognitive capacity, on the other hand,</p><p>is estimated to process in excess of ten million bits per second. Because</p><p>we’re only able to purposefully process a limited amount of information at</p><p>a time, our decisions can become even more impulsive</p><p>if we’re distracted or</p><p>otherwise unable to concentrate.190 An elegant illustration of this “cognitive</p><p>overload” effect was provided by an experiment involving fruit salad and</p><p>chocolate cake.</p><p>Before calls could be made at a touch of a button or the sound of our</p><p>voice, the seven-digit span of a phone number was based in part on the</p><p>longest sequence most people can recall on the fly. We only seem able to</p><p>hold about seven chunks of information (plus or minus two) in our</p><p>immediate, short-term memory.191 So this was the setup: Randomize people</p><p>to memorize either a seven-digit number or a two-digit number to be</p><p>recalled in another room down the hall. As they walk from one room to the</p><p>other, offer each of them the choice of a fruit salad or a piece of chocolate</p><p>cake. Memorizing a two-digit number is easy and presumably takes few</p><p>cognitive resources. Under the two-digit condition, most chose the fruit</p><p>salad. Faced with the same decision, most of those trying to keep seven</p><p>digits in their heads just went for the cake.192</p><p>This can play out in the real world by potentiating the effect of</p><p>advertising. Have people watch a TV show with commercials for unhealthy</p><p>snacks, and, no surprise, they eat more unhealthy snacks compared to those</p><p>exposed to nonfood ads. Or maybe that is a surprise. We all like to feel as if</p><p>we’re in control and not so easily manipulated. The kicker is we may be</p><p>even more susceptible the less we’re paying attention. Randomize people to</p><p>the same two- or seven-digit memorization task while watching a TV show,</p><p>and the snack-attack effect was magnified among those who were more</p><p>preoccupied.193 How many of us have the TV playing in the background or</p><p>multitask during commercial breaks? This research suggests that doing so</p><p>may make us even more impressionable to the subversion of our better</p><p>judgment.</p><p>There’s an irony in all of this. Calls for restrictions on marketing are</p><p>often resisted by invoking the banner of freedom. What does that even</p><p>mean in this context, when research shows how easily our free choices can</p><p>be influenced without our conscious awareness?194 A senior policy</p><p>researcher at the RAND Corporation even went as far as to suggest that</p><p>given the dire health consequences of our unhealthy eating habits, insidious</p><p>marketing manipulations “should be considered in the same light as the</p><p>invisible carcinogens and toxins in the air and water that can poison us</p><p>without our awareness.”195</p><p>Passive Overconsumption</p><p>Food and beverage companies frame body weight as a matter of personal</p><p>choice. But even when we’re not distracted, the power of the “eat more”</p><p>food environment may sometimes overcome our conscious controls over</p><p>eating.196 One look around the room at a dietitians’ convention can tell you</p><p>that even nutrition professionals are vulnerable to the aggressively marketed</p><p>ubiquity of tasty, cheap, convenient calories. This suggests there are aspects</p><p>of our eating behaviors that defy personal insight by flying below the radar</p><p>of conscious awareness.197 Appetite physiologists call the result of these</p><p>subconscious actions passive overconsumption.198</p><p>Remember that brain scan study where the thought of a milkshake lit up</p><p>the same reward pathways in the brain as when cocaine addicts saw videos</p><p>of smoking crack or alcoholics got a whiff of whiskey? That was triggered</p><p>with just a picture of a milkshake. Intellectually, we know it’s only an</p><p>image, but our lizard brains just see survival. Dopamine gets released,</p><p>cravings get activated, and we’re motivated to eat. It’s simply a reflexive</p><p>response over which we have seemingly little control, which is why</p><p>marketers ensure there are pictures everywhere of milkshakes and the</p><p>like.199</p><p>Maintaining a balance between calories in and calories out feels like a</p><p>series of voluntary acts under conscious control, but it may be more akin to</p><p>bodily functions, such as blinking, breathing, coughing, swallowing, or</p><p>sleeping. You can try to will yourself power over any of these, but, by and</p><p>large, they just happen automatically, driven by ancient scripts.200</p><p>Portions Out of Proportions</p><p>During any given two-day period, it seems half of U.S. children consume fast food.201 Though</p><p>attempts have been made to tie fast-food consumption with burgeoning obesity,202 it may just</p><p>be a marker for a lousier diet in general.203 Value-meal bundling and supersizing portions are</p><p>not unique to the fast-food industry. Portion sizes have increased throughout the restaurant</p><p>sector.</p><p>Compared to McDonald’s original sizes in 1955, its burger, fries, and soda offerings have</p><p>increased 250–500 percent.204 But huge food is everywhere—half-pound muffins,205 steak</p><p>house steaks weighing a pound and a half,206 and pasta bowls capable of harboring two</p><p>pounds of Alfredo.207 Have you seen some of the giant chocolate bars these days? At the</p><p>movie theater, a “medium” popcorn today may hold sixteen cups of greased kernels and top</p><p>off at a thousand calories.208</p><p>What role has expanding sizes played in expanding our sizes? To be a plausible driver of</p><p>the obesity crisis, candidate factors would not only match the epidemic curve but also be</p><p>shown demonstrably to cause weight gain. The increases in portion size do seem to parallel</p><p>obesity trends, but the experimental data are limited.209 Manipulating portion sizes at a meal</p><p>or over the course of a day can reliably affect intake,210 perhaps due to the tendency for</p><p>people to take larger and faster bites when provided with bigger portions.211 The longest big-</p><p>portion-size study I could find only lasted eleven days. In that time, however, a 50 percent</p><p>increase in portion sizes increased intake by more than four hundred calories a day. Critically,</p><p>this effect was sustained throughout the duration of the study and did not appear to decline</p><p>over time, suggesting that bigger servings may indeed lead to bigger curvings.212</p><p>Of course, it matters what you’re overeating. Some foods, like many vegetables, have such</p><p>a low calorie density that you would tire from chewing before you could overdo it. You’d</p><p>have to eat a wheelbarrow full of cabbage before you’d ever need to begin worrying about</p><p>overindulging. The portion-size effect has even been used to encourage healthier habits by</p><p>dishing out extra veggies.213 So “simply telling people to eat less of everything may not be the</p><p>most effective message,” wrote one of the principal investigators in the obesity field.214 Thus,</p><p>this is not a call to buy baby carrots and cherry tomatoes. Size may matter, but substance is</p><p>more salient.</p><p>Every Day We Run the Gauntlet</p><p>Not only are food ads ubiquitous, but so, too, is the food being advertised.</p><p>The types of establishments selling food products expanded dramatically in</p><p>the 1970s and 1980s,215 and now that jolt of dopamine and the artificially</p><p>stimulated feelings of hunger are around every turn.216 Candy and snacks</p><p>can be found at the checkout counters of gas stations, drugstores,</p><p>bookstores, and places that used to just sell clothes, hardware, building</p><p>supplies, or home furnishings. The largest food retailer in the United States</p><p>is Walmart.217</p><p>It has become socially acceptable to eat anywhere—in your car, on the</p><p>street, at your desk, or even on a crowded bus. We’ve become a snacking</p><p>society.218 Vending machines are pervasive. Daily eating episodes seem to</p><p>have gone up by about a quarter from the late 1970s, from about four</p><p>occasions a day to five, which potentially accounts for twice the calorie</p><p>increase attributed to increasing meal sizes.219 Snacks and beverages alone</p><p>could account for the bulk of the calorie surplus implicated in the</p><p>epidemic.220</p><p>And think of the children. Here we are trying to do the best for our kids,</p><p>role modeling healthy habits and feeding them healthy foods, but then they</p><p>venture out into a veritable tornado of junk foods and manipulative</p><p>messages. As a commentary in The New England Journal of Medicine</p><p>asked, why should our efforts to protect our “children from life-threatening</p><p>illness be undermined by massive marketing campaigns from the</p><p>manufacturers</p>
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